-r 




Copyright N° _ 

COPYRIGHT DEPOSIT. 



A NURSE'S HANDBOOK 



OF 



OBSTETRICS 



FOR USE IN TRAINING-SCHOOLS 



BY 

JOSEPH BROWN COOKE, M.D. 
ii 

ADJUNCT PROFESSOR OF OBSTETRICS IN THE NEW YORK POLYCLINIC MEDICAL SCHOOL 
AND HOSPITAL; LECTURER ON OBSTETRICS TO THE NEW YORK CITY TRAINING-SCHOOL 
FOR NURSES SURGEON TO THE NEW YOKK MATERNITY HOSPITAL; FELLOW OF THE 
NEW YORK OBSTETRICAL SOCIETY: MEMBER OF THE AMERICAN MEDICAL ASSO- 
CIATION THE MEDICO-SURGICAL SOCIETY, THE MANHATTAN CLINICAL 
SOCIETY, THE YALENTINE MOTT SOCIETY, ETC. 



Third Edition, Revised 



PHILADELPHIA AND LONDON 
B. LIPPINCOTT COMPANY 



UGRARY of CONGRESS 
Two Copies Reeclved 

AUG 18 1907 

Ctpyncht Entry 

CLASS A XXc, No, 

COPY B. 



A 



Copyright, 1903, by J. B. Lippincott Company 



Copyright, 1905, by J. B. Lippincott Company 



Copyright, 1907, by J. B. Lippincott Company 



PRINTED BY J. B. LIPPINCOTT COMPANY, PHILADELPHIA, U.S.A. 



^ 



TO THE PUPILS 



NEW YORK CITY TRAINING-SCHOOL FOR NURSES 



WHOSE USE THIS BOOK WAS ESPECIALLY 
WRITTEN. IT IS MOST CORDIALLY 



Dedicate* 

BY THE AUTHOR 



PREFACE TO THE THIRD EDITION 

In going over this work for the third time, the author is 
gratified to find how few material changes seem to him necessary, 
either in text or illustrations. It may be noted, however, that he 
has given up entirely the use of lysol or any similar preparation, 
and has returned to the old-fashioned Tincture of green soap for 
cleansing purposes, and sterile normal salt solution for irrigation 
and douches ; but, beyond this, no change of any consequence has 
been made. 

The author can only renew his thanks to the thousands of 
nurses throughout the land who, by the seal of their approval, 
have made the book a success from the day of its publication. 

J. B. C. 
616 Madisox Avexue, New York. 
March 24, 1907. 



PREFACE TO THE FIRST EDITION 

This book was written to supply a need that has long been 
felt in the Training-School for Nurses with which the author is 
associated, and one which has doubtless been experienced in 
other institutions of the same character. 

The trained nurse of to-day devotes not less than two, and 
usually three, years of her life to the study of her profession, a 
period of time which, until recently, was regarded as sufficient 
for the medical student to gain all the knowledge necessary for 
the acquisition of his diploma as a fully qualified physician and 
surgeon. 

In spite of this, there are few if any strictly technical text- 
books written expressly to meet the requirements of the pupil- 
nurse. She has, of course, her works on " Nursing," but when 
she takes up the purely medical or surgical side of her subject, 
as she must to a certain and not very limited extent if she is to 
perform her duties thoroughly and intelligently, she is obliged 
to turn for her information to books written solely for the use 
of physicians and medical students, and filled with incompre- 
hensible technicalities and confusing statistics and discussions. 

This makes the training of the pupil-nurse a problem of 
considerable difficulty not only to herself, but to her teachers 
and other instructors, and in the matter of obstetrics the condi- 
tion of affairs seems to be especially marked. 

The book-shops are filled with small volumes on " Maternity 
Nursing," " The Hygiene of Pregnancy," and similar subjects, 
but practically all of these works are written with a double pur- 

7 



8 PREFACE. 

pose, and are so worded and arranged that they can be used by 
the prospective mother herself as well as by the nurse. Between 
these short, incomplete, and purposely " popular" books and the 
strictly medical work, there is nothing to which the nurse can 
appeal for information ; and the present volume is offered as a 
means of filling in the gap. It is intended to contain all of the 
science and art of obstetrics that a nurse need know in order 
to practise her profession in an intelligent manner consistent 
with her position as a scientifically educated woman, combined 
with a clear exposition of the principles and practice of mater- 
nity nursing. Statistics, discussions, and unsubstantiated theories 
have been entirely omitted, and an effort has been made to pre- 
sent the subject-matter in a way that will be perfectly clear to 
the beginner in the study of nursing. 

It has been suggested to the author that a book written on 
the plan of the present volume would have a tendency to over- 
educate the nurse and make her feel that in point of knowledge 
she 'stood on an equal plane with the physician. The absurdity 
of this contention is based upon its inherent inconsistency, for 

" A little learning is a dangerous thing," 

and education and intelligence are the best and surest safeguards 
against insubordination and usurpation of authority. 

The lieutenant never questions the word nor criticises the 
action of his captain or colonel, yet both are educated on pre- 
cisely the same lines ; but the private, who knows nothing of 
the science of war, and is required to work blindly and unques- 
tioningly, is constantly ventilating his ideas and lamenting the 
ignorance of his superiors to any one who is foolish enough to 
listen. 

Repetitions in the book are frequent and intentionally so. 
Details are treated with the utmost minuteness, and the Glossary 



PREFACE. 9 

contains many words not to be found in the text but included to 
facilitate collateral reading and the understanding of occasional 
remarks made by physicians. 

The profusion of illustrations, of which seventy-six are origi- 
nal and were made especially for this work, adds greatly to the 
practical value of the book and has been rendered possible by 
the generosity of the publishers, whose unfailing courtesy and 
assistance at all times is most highly appreciated by the author. 

The author wishes also to express his thanks and acknowl- 
edge his indebtedness to Miss Mary S. Gilmour and Miss Theo- 
dora H. LeFebvre, the Superintendent and Assistant Superin- 
tendent of the New York City Training-School for Nurses, who 
have most kindly read the manuscript and made a number of 
valuable corrections and suggestions, and to Dr. G. E. McCart- 
ney, who has aided him materially in various ways. 

J. B. C. 
240 West One Hundred and Thirty-eighth Street, New York. 
March 10, 1903. 



CONTENTS 

¥¥ 

CHAPTER PAGE 

I. — Introduction 19 

II. — The Pelvis 22 

III. — The Female Organs of Generation 28 

IV. — Ovulation and Menstruation 37 

V. — Fetal Development 43 

VI. — The Physiology of Pregnancy 62 

VII. — The Disorders of Pregnancy 71 

VIII. — The Signs and Symptoms of Pregnancy 98 

IX. — The Management of Pregnancy 105 

X. — The Nurse's Outfit 119 

XI. — The Patient's Outfit 123 

XII. — The Mechanism of Labor 129 

XIII. — The Phenomena of Labor 139 

XIV. — Preparations for Labor 144 

XV. — The Conduct of Labor 152 

XVI. — Operative Delivery 177 

XVII. — Accidents and Emergencies 201 

XVIII. — The Physiology of the Puerperium 224 

XIX. — The Management of the Puerperium 228 

XX. — The Disorders of the Puerperium 248 

XXI. — Abortion and Miscarriage 261 

XXII. — The Care of the Normal Infant 271 

XXIII. — The Premature and Feeble Infant 285 

XXIV. — The Accidents, Injuries, and Diseases of the New-Born 299 

XXV. — Infant Feeding 310 

XXVI. — Maternal Impressions and the Control of Sex 343 

Key to Pronunciation 347 

Glossary 349 

Index 387 

11 



LIST OF ILLUSTRATIONS 

FIGURE PAGE 

1. The normal female pelvis 22 

2. The pelvic inlet 24 

3. Male and female pelvis 25 

4. Female pelvis deformed by osteomalacia 26 

5. Harris's pelvimeter 26 

6. Measuring the distance between the crests of the ilia 26 

7. Internal pelvimetry 27 

8. External organs of generation 28 

9. Internal organs of generation 30 

10. The internal organs of generation, seen from above 31 

11. The uterus and its appendages 31 

12. The cavity of the uterus 32 

13. Ovary and tube of a girl twenty-four years old 34 

14. Mammary gland of a woman during lactation , . . . . 35 

15. Longitudinal section through ovary of a woman twenty-two days 

after the last menstruation t>7 

16. Longitudinal section of ovary of a woman on the first day of 

menstruation 38 

17. Human spermatozoa 43 

18. First stages of segmentation of the ovum of a rabbit 44 

19. Uterus with decidua in beginning pregnancy 46 

20. Normal position of foetus in utero 47 

21. Fetal surface of the placenta 49 

22. Maternal surface of the placenta 49 

2T). Human ovum at the end of the first month 50 

24. Outline of human embryo of about four weeks . 51 

25. Human fcetus at the end of the third month 51 

26. Skeleton of infant at term 52 

27. Fetal skull, side view 54 

28. Diagram of circulation after birth. Adult type 57 

29. Diagram of circulation before birth. Fetal type 58 

13 



l 4 LIST OF ILLUSTRATIONS. 

FIGURE PAGE 

30. Striae gravidarum, or Lineae albicantes 63 

31. The breasts of pregnancy 66 

32. Abdominal pigmentation 68 

33. Varicosities of the lower extremities JJ 

34. Ectopic gestation 93 

35. Placental attachment 95 

36. Marked pigmentation of breast 101 

yj. Size of the uterus at each month- of pregnancy 103 

38. Operating gown and case 119 

39. Proper costume for obstetrical nurse . 120 

40. Scales and hammock for weighing infant 121 

41. Vertex presentation 130 

42. Flexion of head during second stage 132 

43. Extension of the head in anterior presentations of the vertex .... 133 

44. External rotation 134 

45. Internal rotation and extension , 135 

46. Shape of head of child born in face presentation 136 

47. Shape of head of child born in brow presentation 136 

48. Face presentation 136 

49. Breech presentation 137 

50. Prolapse of arm in transverse presentation 137 

51. Bassinette 146 

52. Preparation of bed for labor. First stage 148 

53. Preparation of bed for labor. Second stage 148 

54. Arrangement of bed, table, and chair for normal labor 150 

55. Arrangement of sheets for vaginal examination 156 

56. Vaginal examination 156 

57. Kelly pads 157 

58. Beginning of second stage of labor. Patient bracing against chair 

and pulling on sheet at the height of a pain 159 

59. Esmarch outfit for the administration of chloroform 159 

60. Administration of chloroform 161 

61. Administration of ether 164 

62. Delivery of placenta in dorsal position 169 

63. Holding back the head to prevent sudden expulsion 168 

64. Infant suspended by heels. Nurse slapping its back to excite re- 

spiratory movements 169 



LIST OF ILLUSTRATIONS. 15 

FIGURE PAGE 

65. Square knot 170 

66. Granny knot I7 1 

67. Delivery of placenta and membranes I7 2 

68. Delivery of the head in breech cases 173 

69. Arms extended in breech delivery 175 

70. Locked twins 176 

71. Internal version 177 

72. Combined or bipolar version 178 

72,. Lithotomy position 179 

74. Forceps applied to head at brim 181 

75. Walcher posture 181 

76. Elliott's forceps 182 

77. Simpson's forceps 183 

78. Tucker-McLane forceps 183 

79. Tarnier axis-traction forceps 183 

80. Barnes's bags 185 

81. Champetier de Ribes bag 185 

82. Bulb and valve, or " Davidson" syringe 185 

83. Bag in grip of forceps 186 

84. Pelvic tumor preventing delivery 187 

85. Kelly pad in position under patient 188 

86. Sterile salt solution in flasks 189 

87. Sponge made of cotton and gauze 189 

88. Sponge-holder 189 

89. Intestinal pad of folded gauze 190 

90. Gauze packing 190 

91. Galbiati knife 192 

92. Scalpels 194 

93. Needle-holder 194 

94. Naegele's perforator 196 

95. Braun's cranioclast 196 

96. Tarnier's basiotribe 196 

97. Impacted shoulder presentation 197 

98. Braun's key-hook 197 

99. Braun's hook applied 198 

100. Long, blunt scissors. For decapitation and evisceration 198 

101. Bougie for the induction of labor 199 



16 LIST OF ILLUSTRATIONS. 

FIGURE PAGE 

102. Sims's position 200 

103. Concealed hemorrhage 202 

104. Rupture of the uterus 205 

105. Complete inversion of the uterus 206 

106. Prolapse of the umbilical cord 208 

107. Knee-chest position 208 

108. Trendelenburg position 209 

109. Manual extraction of the placenta 214 

1 10. Aspirating needle 220 

in. Saline infusion under the breast . 220 

112. Figure-of-eight ligature. For controlling secondary hemorrhage 

from the umbilicus , 222 

1 13. Holding the fundus after delivery 229 

114. Douche-pan 231 

115. Fountain syringe 233 

1 16. Teufel's abdominal supporter 235 

1 1 7. Abdominal binder 236 

1 18. Glass catheter 240 

119. Proper method of inserting catheter 241 

120. Method of withdrawing catheter 242 

121. Proper method of introducing douche-tube 244 

122. Massage of the breast 254 

123. Nipple shield 255 

124. Author's breast-binder . 256 

[25. Pattern of author's breast-binder 257 

126. Lithotomy position 263 

127. Author's leg-holder . , 264 

128. Robb's leg-holder 264 

129. Sims's speculum 265 

130. Schfoeder's vaginal retractor 265 

131. Bullet-forceps . 265 

132. Modified Goodell-Ellinger dilator 265 

133. Uterine sound 266 

134. Placenta-forceps with heart-shaped jaws 266 

135. Curettes 266 

136. Sponge-holder 266 

137. Two-way catheter ,.,..,, 267 



LIST OF ILLUSTRATIONS. 17 

FIGURE PAGE 

138. Patient ready for curettage 269 

139. Method of dressing the umbilical cord 273 

140. Folding rubber bath-tub 274 

141. Double wash-basin 275 

142. Paper bags pinned together 275 

143. Diagram of nursery 277 

144. Lowering infant into bath 279 

145. Infant's long clothes 281 

146. Infant's night-gown 283 

147. Pattern for improvised cotton jacket 288 

148. Improvised turban of gauze and cotton for premature infant . . . 289 

149. Improvised cotton jacket, blanket, and turban 289 

150. Infant premature at twenty-eighth week 290 

151. Tarnier's incubator, exterior 291 

152. Tarnier's incubator, interior 292 

153. Hot- water jug 292 

154. Premature infant properly attired 294 

155. English breast-pump 295 

156. Feeder for premature infant 297 

157. Infant premature at thirty weeks 298 

158. Facial paralysis of new-born child 301 

159. Caput succedaneum 301 

160. Double cephalhematoma 302 

161. Thumb-forceps 304 

162. Spina bifida of dorsal lumbar region 305 

163. Spina bifida. Spontaneous cure 306 

164. Hernia button 307 

165. Method of attaching hernia button 307 

166. Opisthotonos 309 

167. Soft, flabby breasts 311 

168. Two-ounce vial with nipple 313 

169. Chapin dipper 330 

170. The " Sloane Maternity" measuring-glass 333 

171. Nursing-bottles 335 

172. Testing size of opening in nipple 336 

173. Steam-sterilizer 339 

174. Freeman pasteurizer 339 

2 



A NURSE'S 

Handbook of Obstetrics 

i 

Introduction 

In a paper read recently before one of the great medical 
societies of New York the gynaecologist was styled " that obstet- 
rical camp-follower," and this characterization may well serve 
as a text for a dissertation on obstetric nursing. 

Practically all women who consult the gynaecologist are mar- 
ried, have borne children, and date their troubles from the birth 
of one or another child, and it is safe to say that the compara- 
tively few unmarried women who seek advice for the relief of 
pelvic disorders would be in infinitely worse condition than they 
are if they had passed through the ordeal of pregnancy and 
labor. 

The amount of good for womankind that nurses can accom- 
plish by the dissemination of judicious advice concerning the 
requirements of the pregnant state and by intelligent care of 
parturient and puerperal cases, probably exceeds in many ways 
the best efforts of the physician. Especially among primi- 
gravidae does this hold true, for women who have never borne 
children are often remarkably diffident in regard to their condi- 
tion, and unless the early symptoms of pregnancy are exception- 
ally severe, they will neglect to place themselves under medical 
care until much mischief may have been done. 

When nurses, as a class, will impress upon women who may 

19 



20 A NURSE'S HANDBOOK OF OBSTETRICS. 

come under their notice the importance, not only to themselves 
but to their infants, of consulting and implicitly following the 
directions of a skilful obstetrician as soon as they have reason 
to suspect that the}- are pregnant, they will save a large number 
of these patients many visits to the gynaecologist in after years. 

A nurse can, with propriety, volunteer advice of this kind 
when a physician, taking the same stand, would often be unjustly 
suspected of ulterior motives, and her opportunities for doing 
so are greater than his in the exact proportion in which a woman 
will discuss a delicate subject with another woman more fre- 
quently and more freely than with a man. 

Regarding nursing in the light of a noble profession, closely 
allied to that of medicine, no opportunity for aiding and perma- 
nently benefiting humanity will ever be overlooked, and scientific 
supervision of pregnancy, labor, and the puerperium can do 
more in this respect than all other branches of nursing com- 
bined. 

As the writer has expressed in another place, let the pregnant 
woman be taken in hand at the very beginning of her pregnancy 
and put in condition to withstand the ordeal through which she 
has to pass, much as the athlete is " trained" for months before 
the encounter in which he is to figure. 

It may be stated, as a general rule, that no woman should die 
or even be seriously invalided as a result of pregnancy if she is 
under proper care from the beginning of gestation, and it rests 
with the nurses of modern times more than with the physicians 
to see that every woman is afforded such care and attention as 
will insure the successful outcome of her case. 

The key-note of success in obstetric practice lies in a thor- 
ough knowledge of the patient's exact condition long before 
labor occurs and in ample preparation for . delivery and after 
care, so that the labor may be conducted with every attention to 
aseptic detail and modern surgical method. 

Twentieth century civilization has done much to retard the 
physical development of women in general, and, among those 
w r ho are in a position to afford the services of a graduate nurse, 
very few have sufficiently robust constitutions and normally de- 



INTRODUCTION. 21 

veloped pelves and generative organs to make labor and its after 
effects anything but a matter of considerable moment. 

Unless the physician has been afforded an opportunity to 
build up their general health and keep a watchful eye on the 
behavior of their bodily functions, and unless the nurse has 
made careful and judicious preparations for conducting their 
labors in a thoroughly aseptic manner, complications may arise 
at the last moment which may result in permanent invalidism, 
if not in the death, of the mother or child. 

Obstetric nursing presents many unattractive features, for 
after labor there are two patients instead of one to be cared for, 
but it offers so many and so great opportunities for the advance- 
ment of " preventive medicine" that the writer cannot but look 
with considerable disfavor upon that large and constantly in- 
creasing class of hospital nurses who regard maternity cases as 
entirely beneath their dignity and who leave these unfortunate 
patients in the care of unskilled attendants, only to nurse them 
afterwards when they reach the operating-table of the gynae- 
cologist. 



II 

The Pelvis 

The pelvis (Fig. i) is that portion of the skeleton which 
lies between the spinal column and the lower extremities. It is 




Fig. i. — The normal female pelvis. (Garrigues.) A, sacrum; £, coccyx; C, crest of 
the ilium; D, acetabulum; E, spine of the ischium; F, symphysis pubis ; G, spine of the 
pubis ; H, obturator foramen ; /, tuberosity of the ischium ; J, J, J, linea terminalis. 

composed of four bones, — the sacrum and coccyx behind, and 
the innominate bones (ossa innominata) at the sides and in front. 
Each innominate bone (os innominatum) is divided by anato- 
mists into three parts, — the ilium, the ischium, and the pubis. 

The ilium, which is the largest portion of the bone, is broad, 
thin, concave on its inner aspect, and lies above the narrow con- 
stricted portion of the pelvis. Like its fellow of the opposite 
side, it is joined to the sacrum behind, and its upper flaring 
22 



THE PELVIS. 



23 



border forms the prominence of the hip, or crest of the ilium, 
commonly spoken of as the " hip bone." 

The pubis joins directly in front, in the median line, with 
its opposite fellow, and closes, anteriorly, the cavity of the pelvis. 

The ischium, which is that portion of the innominate bone 
lying beneath the ilium, is not of importance to the obstetric 
nurse, although it is of interest to know that it occasionally pre- 
sents bony projections (exostoses) of sufficient size to obstruct 
the descent of the head during labor. 

The sacrum is a triangular, wedge-shaped bone, consisting 
of five rudimentary vertebrae welded together, and lies at the 
back part of the pelvis, between the ilia (plural of ilium), closing 
in the cavity behind. Its upper surface, or base, is broad and 
flat, and supports the spinal column (" backbone") and with it 
the entire weight of the body. Its apex points downward and 
forward, and to it is attached 

The coccyx, a very small triangular bone, resembling some- 
what in appearance a miniature sacrum and being possibly the 
remains of a prehistoric caudal appendage, or tail. 

Regarded as a whole, the pelvis may be described as a deep, 
bony basin resting on the upper extremities of the two femora 
(plural of femur), or thigh bones, and supporting the spinal 
column, which carries the weight of the trunk, the head, and 
the upper limbs. The flaring surfaces of the ilia make a sort 
of funnel to guide the foetus into this basin, which, having no 
bottom, forms a bony canal through which the child has to pass 
at the time of labor. 

The most constricted portion of the pelvis is called the brim, 
or inlet (Fig. 2), and is, naturally, of the greatest obstetric im- 
portance; for, as a chain is only as strong as its weakest link, 
so is a canal only as broad as its narrowest part, and, except in 
certain cases of deformity, any child that can pass safely through 
the brim can be delivered without any further difficulty. 

The brim of the pelvis is bounded behind by that portion of 
the upper anterior surface of the sacrum, which projects farthest 
forward and is called the "promontory of the sacrum;" on the 
sides by the lower borders of the ilia; and in front by the two 



24 



A NURSE'S HANDBOOK OF OBSTETRICS. 



pubic bones, which meet in the median line and form the " sym- 
physis pubis." 




Fig. 2. — The pelvic inlet. (Garrigues.) A B, anteroposterior or true conjugate diame- 
ter; CZ>, left oblique diameter; E F, right oblique diameter; G H, transverse diameter; 
A S, sacrocotyloid distance •; IK, crest of the ilium. 

The contour of the inlet is more or less heart-shaped because 
of the jutting forward of the promontory of the sacrum, and the 
most important diameter of the pelvis is the distance between the 
promontory and the symphysis. If this is normal (ten centi- 
metres, or about four and one-quarter inches), it is almost cer- 
tain that the entire pelvis is normal, and that the child can be 
born without any serious difficulty. 

The articulations (joints) of the pelvis, which possess ob- 
stetric importance, are four in number. Two are behind, between 
the sacrum and the ilia on either side, and are termed the sacro- 
iliac synchondroses (plural of synchondrosis) ; one is in front, 
between the two pubic bones, and is called the symphysis pubis; 
and the last, of little consequence, is that between the sacrum 
and coccyx, — the sacro-coccygeal articulation. 



THE PELVIS. 



25 



All of these articular surfaces are lined with fibro-cartilage, 
which becomes thickened and softened during pregnancy, and a 
certain definite, though very limited, motion in the joints is 
essential to a normal labor. Even an ankylosis of the sacro- 
coccygeal articulation, preventing the tilting backward of the 
coccyx at the time of delivery, may necessitate the use of for- 
ceps, and, in the operation of symphyseotomy, which consists 
in cutting through the symphysis pubis and so separating the 
pubic bones, no increase in the capacity of the pelvis could be 
secured were it not for a very distinct hinge-like motion at the 
sacro-iliac synchondroses. 

The pelvis is lined with muscular tissue, which provides a 
smooth slippery surface over which the fcetus has to pass during 
labor, and its bones are bound together by ligaments, which 
become softened and slightly lengthened as pregnancy advances. 

Comparing the female with the male pelvis (Fig. 3), we 
find that the former is especially adapted to the uses for which 




Fig. 3. — Male and female pelvis. A, male pelvis — narrow, heavy, compact; B, female 
pelvis — broad, light, capacious. 



it is designed. It is shallow, but very capacious, lighter in struc- 
ture and smoother than the male pelvis, which is deep, conical, 
rougher for muscular attachment, and more compact. 

The entire problem in obstetrics consists in the safe passage 
of the fully developed fcetus through the pelvis of the mother. 
Slight pelvic contractions, resulting in tedious or instrumental 



26 



A NURSE'S HANDBOOK OF OBSTETRICS. 



deliveries, are comparatively common, while any such marked de- 
formity as depicted in Fig. 4 would render labor by the natural 




Fig. 4. — Female pelvis deformed by osteomalacia. (Garrigues.) 

passages entirely out of the question. For these reasons the 
pelvis of every pregnant woman should be measured carefully 
at a sufficiently early date to enable the physician to determine 
definitely the proper course to pursue. 




Fig. 5. — Harris's pelvimeter. 



The external pelvic measurements are taken with an instru- 
ment called a pelvimeter (Fig. 5), which acts on the principle 



THE PELVIS. 



27 



of a carpenter's or plumber's calipers. The patient lies on her 
side or back, according to the diameters to be measured, with 
the abdomen exposed, as shown in Fig. 6. The internal pelvic 
measurements, for determining the actual diameters of the brim, 
are usually made by inserting two fingers into the vagina and 
up to the promontory of the sacrum and estimating the various 
dimensions in this manner (Fig. 7). 




Fig. 7. — Internal pelvimetry. Measuring the distance between the promontory of the 
sacrum and the lower border of the symphysis pubis. 

The importance of the knowledge gained through the skilful 
performance of external and internal pelvimetry cannot be over- 
estimated, and it should never be neglected in the case of a 
woman pregnant for the first time nor in any case in which the 
patient has suffered previously from difficult or tedious labors. 

In cases of slight contraction the induction of labor two or 
three weeks before term may be all that is necessary, while the 
existence of marked deformity may call for the performance of 
Cesarean section as the only alternative. It is to be kept in 
mind that the higher we ascend in the social scale the more 
frequently do we encounter pelvic deformities of varying de- 
grees, due to faulty development superinduced by lives of luxury 
and indolence, and that the class of patients coming under the 
care of the graduate nurse presents a far greater proportion of 
such deformities than is found among women in the lower walks 
of life. 



Ill 

The Female Organs of Generation 

The female organs of generation are divided into two 
groups, the external and the internal, which are connected by the 
vagina. 

The external organs, taken as a whole (Fig. 8), constitute 
the vulva, and consist of — 




Fig. 8. — External organs of generation. 
C, meatus urinarius ; D, clitoris; E, mons veneris ; F, perineum ; G, anu 
vagina. 



A, A, labia majora ; B, B, labia minora; 
ic • p n&-ino.im ■ n r,„„c.. H,entrance to 



The mons veneris, a firm, cushion-like formation covered 
with hair and lying directly over the symphysis pubis. 

The labia majora, or greater lips, made up of adipose tissue 

(fat) and covered externally with skin and hair and internally 

with mucous membrane. They begin in the median line at the 

lower border of the mons veneris and extend downward and 

28 



THE FEMALE ORGANS OF GENERATION. 29 

backward, on either side, to meet at a point termed the four- 
cJiette, which is almost invariably torn at the first labor. 

The labia minora, or lesser lips, lie entirely within the vulva, 
except in the case of infants and of women who have borne chil- 
dren or are much emaciated. They are covered entirely with 
mucous membrane, and their upper extremities are divided into 
two parts, one passing above and one below (and so forming a 
hood for) 

The clitoris. This is a small reddish tubercle situated about 
half an inch behind the upper and anterior junction of the labia 
majora. 

The meatus urinarius, commonly spoken of as the " meatus," 
is the external opening of the urethra, which is the canal (about 
one and one-half inches in length) leading to the bladder. The 
meatus lies directly back of the clitoris and about three-quarters 
of an inch from it. When the labia are separated it appears as 
a small dimple in the median line under the symphysis. 

The vagina is a musculo-membranous canal, five to six inches 
in length, leading from the vulva to the uterus and lying wholly 
within the true pelvis. It is lined with mucous membrane, the 
secretion of which possesses marked germicidal properties. In 
consequence of this fact the vagina is always aseptic except in 
the presence of disease or very soon after direct infection from 
without, and for this reason a vaginal douche should never be 
given before labor unless it is specially ordered by the physician. 
Under ordinary circumstances such a douche can do no good, 
and it is certain to do actual harm by removing the natural and 
aseptic lubricant of the vagina, even if it does not, through 
carelessness of preparation or administration, introduce infection 
where none had existed previously. 

The internal organs of generation (Figs. 9 and 10) consist of 
the uterus, the Fallopian tubes, and the ovaries. 

The uterus, or womb (Fig. 11), is a hollow, pear-shaped 
organ about three inches in length in the non-pregnant state. 
It is composed of muscular tissue, covered externally almost 
wholly with peritoneum and internally with mucous membrane, 
and is suspended in the pelvis by means of a number of ligaments 



30 



A NURSE'S HANDBOOK OF OBSTETRICS. 



arranged in pairs and stretching across from the uterus to the 
sides of the pelvis or to other pelvic organs. This arrangement 
of the ligaments is such that the uterus is allowed considerable 
freedom of motion, and its position varies slightly with respira- 
tion, with the posture of the woman, and with the condition of 
the bowels and bladder. In other words, the uterus has no 




Fig. 9.— Internal organs of generation. (Keating and Coe.) Showing the uterus in its 
normal position between the bladder and the rectum. The vagina lies between the lower 
border of the bladder and the meatus urinarius above and the rectum and anus below, 
separated from the latter by the perineum. 

intimate attachment to any fixed point, but hangs in the pelvis 
in a way to permit of its enormous enlargement during preg- 
nancy, — from about the size of an egg before conception has 
occurred to that of a fairly large pumpkin at the time of labor. 
The uterus lies in about the centre of the pelvis, below the brim, 
with the bladder in front and the rectum behind, so that, of 



THE FEMALE ORGANS OF GENERATION. 



31 




Fig. 10.— The internal organs of generation, seen from above. (Keating and Coe.) 




Fig. 11.— The uterus and its appendages. (Keating and Coe.) The ovaries are the almond- 
shaped bodies lying between the uterus and the extremities of the Fallopian tubes. 



32 



A NURSE'S HANDBOOK OF OBSTETRICS. 



necessity, a full rectum will force it forward and a distended 
bladder will tilt it backward. Its upper, rounded border is called 
the fundus, and its lower, narrowed portion the cervix, while that 
part between the fundus and the cervix is termed the body of 
the uterus. The cervix projects into the vagina for a distance 
of about half an inch, much as a cork projects into the neck of 
a bottle. 




C 

;. — The cavity of the uterus. (Garrigues.) c, vagina; e, external os ; d, internal 
os ; f, fundus, the letter being placed over the entrance of the Fallopian tube. 



The spaces between the sides of that part of the cervix which 
extends into the vagina and the vaginal walls are termed for- 
nices (plural of fornix), and are divided into four parts. The 
anterior fornix is between the anterior wall of the cervix and the 
anterior vaginal wall; the posterior fornix is between the pos- 
terior vaginal wall and the posterior wall of the cervix; the 
lateral fornices are the spaces between the cervix and the vaginal 
walls on either side. 

The cavity of the uterus (Fig. 12) is lined with mucous 
membrane, and is divided into two parts, — the cavity of the body 
and the cavity of the cervix. The cavity of the body is tri- 



THE FEMALE ORGANS OF GENERATION. 



33 



angular in shape, with its apex pointing downward, while that 
of the cervix is spindle-shaped. 

There are three openings into the cavity of the uterus. The 
external opening, called the external os (Latin for mouth), is 
in the centre of the cervix as it projects into the vagina. It is 
very small in the non-pregnant state, barely admitting a probe, 
but at the time of labor it dilates to a size sufficient to permit the 
passage of the foetus. The other openings are at the upper angles 
of the triangular cavity of the body and lead into the Fallopian 
tubes, which will be described later. As the Fallopian tubes open 
directly into the peritoneal cavity, it will be seen that there is a 
direct avenue from the peritoneum to the outer world, through 
the Fallopian tubes, the uterus, and the vagina. 

The cavity of the cervix is slightly distended above the ex- 
ternal os, to become contracted again at its junction with that 
of the body. This second contraction is termed the internal os, 
and it is because of these two points of contraction that the 
cavity of the cervix acquires its spindle shape. 

The Fallopian tubes (see Fig. n) are two trumpet-shaped 
tubes, from four to five inches in length, extending from the 
upper angles of the uterus, just below the fundus, towards the 
sides of the pelvis. Between their outer extremities and the 
uterus, on either side, are found 

The ovaries (Fig. 13), which are the germ-producing organs 
of the woman and about the size and shape of an English walnut. 
Each ovary contains in its substance at birth a vast number of 
germs or ovules (from Latin, meaning "little eggs"), and, 
beginning at about the time of puberty and occurring at or about 
every menstrual period, one or possibly two of these ovules 
enlarges, approaches the surface of the ovary, escapes into the 
Fallopian tube, and so passes on into the uterus. 

The ovule which has " matured" in this way is the only one 
that can be impregnated by the male germ, and if there is no 
male element present in the Fallopian tube, where impregnation 
usually occurs, nothing results beyond the usual menstrual phe- 
nomena. 

The perineum (see Fig. 9) can hardly be considered as 

3 



34 A NURSE'S HANDBOOK OF OBSTETRICS. 

belonging to the organs of generation, but it may best be de- 
scribed in this chapter. Briefly, and as far as the nurse is con- 
cerned, it is the triangular mass of tissue which separates the 
vagina from the rectum. Its upper surface is covered by the 



^3 

> 



L0S± 



Fig. 13.— Ovary and tube of a girl twenty-four years old. (Waldeyer.) U, uterus ; 
T, tube ; LO, ovarian ligament ; o, ovary ; x, limit of peritoneum ; b, cicatrices of ruptured 
Graafian follicles. 



lower wall of the vagina, its posterior surface is in contact with 
the rectum, and its external surface is covered with skin and 
lies between the lower angle of the vulva and the anus. The 
perineum forms the floor of the genital canal, and in certain 
difficult labors it is torn, when the head is born, to an extent 
varying all the way from a slight nick in the skin to a deep lacer- 
ation extending through the anus into the rectum itself. 

The mammae {mammary glands or breasts) are two highly 
specialized sebaceous glands located on either side of the an- 
terior wall of the chest between the third and seventh ribs. They 
secrete the milk which serves as the sole nourishment of the 
infant during the early months of its life, and they are abun- 
dantly supplied with nerves and blood-vessels and intimately 
connected, by means of the sympathetic system, with the uterus 
and other generative organs. This sympathetic relation is espe- 
cially noticeable when the infant nurses immediately after birth 



THE BREASTS. 



35 



and reflex uterine contractions result from the irritation of the 
nipple caused by the suckling. 

The breasts of a woman who has never borne a child are 
conical or hemispherical in form, but their size and shape vary 
greatly in women who have nursed one or more infants. 

The breasts are made up of glandular tissue and fat, and 
each organ is divided into fifteen or twenty lobes, which are 
separated from each other by fibrous and fatty walls and sub- 
divided into numerous lobules (little lobes) (Fig. 14). The 




Fig. 14.— Mammary gland of a woman during lactation, with lactiferous ducts and sinuses 

(Luschka.) 



lobules are composed of acini (plural of acinus), in which the 
milk is formed, and as the ducts approach the nipple they are 
dilated to form little reservoirs in which the milk is stored, but 
contract again as they pass into the nipple. 

The external surface of the breast is divided into three por- 
tions, as follows: (a) The white, smooth, and soft area of 
skin extending from the circumference of the gland to the 
areola, (b) The areola, which surrounds the nipple and is of 



36 A NURSE'S HANDBOOK OF OBSTETRICS. 

a delicate pinkish hue in blondes and a darker rose-color in 
brunettes. Under the influence of gestation the areola becomes 
darker in shade, and this pigmentation which is more marked 
in brunettes than in blondes, constitutes, in many cases, a valu- 
able sign of pregnancy (see Figs. 31 and 36). (c) The nipple, 
a large conical papilla projecting from the centre of the areola 
and having at its summit the openings of the milk ducts. 



IV 

Ovulation and Menstruation 

As stated in the previous chapter, the ovaries contain in their 
substance, at birth, a great number (about seventy thousand) of 
undeveloped ova or " eggs," and it is unnecessary to say that 
these ova are microscopical in size. 

Beginning, in this climate, at about the thirteenth year of 
age and occurring about once a month, one of these ova enlarges 
and approaches the surface of the ovary. This enlarged ovum, 
lying directly under the surface of the ovary, constitutes what is 
known as the Graafian follicle (Fig. 15), and projects slightly, 




Fig. 15. — Longitudinal section through ovary of a woman twenty-two days after the last 
menstruation. (Leopold.) m.f., mature Graafian follicle; fir., most prominent point of 
follicle, where the rupture may be expected. 



like a small pimple. The Graafian follicle then becomes thinned 
at one point, where it soon bursts and allows the ovum to escape 
into the Fallopian tube (Fig. 16). 

37 



38 A NURSE'S HANDBOOK OF OBSTETRICS. 

Once within the Fallopian tube, the ovum makes its way into 
the uterus, and, if unimpregnated by the male element, it loses 
its vitality in a few days and is cast off with the menstrual flow. 




Fig. 16. — Longitudinal section of ovary of a woman on the first day of menstruation, 
with one burst follicle opening on the surface and other follicles in different stages of 
development. (Leopold.) 

When, however, the male germ is present it meets and pene- 
trates the ovum, usually while it is still in the Fallopian tube. 
The ovum thus impregnated passes on, as before, into the uterus, 
but instead of being cast out in the menstrual discharge it 
becomes adherent to the wall of the uterus and develops into 
the foetus and its envelopes, the point of attachment to the uterine 
wall being the site of the placenta in later months. 

It is, of course, evident that of the vast number of ova con- 
tained in the ovaries, a comparatively small number ever mature 
and are prepared for fertilization by the male element, and that 
of these, so prepared by maturation and discharge from the 
ovary, very few are actually impregnated ; for the impregnated 
ova of any woman are accurately measured by the number of her 
children plus the number of her miscarriages. 

This lavish provision of nature against any possible inter- 
ference with the propagation of the human race is also found in 
the male, for, of thousands of male elements (spermatozoa) 
deposited at one time within the vagina, very few make their way 
through the external os and the uterus to the Fallopian tube, 
and, of these, but one is successful in penetrating the wall of 
the ovum and causing pregnancy. 

This process, by which the ovum develops and is cast out 
from the ovary into the Fallopian tube, to be impregnated or 
not as the case may be, is termed ovulation, and while it is usually 



MENSTRUATION. 



39 



accompanied by menstruation, neither process is dependent upon 
the other. 

The accuracy of this last statement is shown by the following 
incontrovertible facts : Without ovulation there can be no preg- 
nancy, and yet pregnancy has occurred before the establishment 
of menstruation ; it has occurred after menstruation has ceased ; 
and it not infrequently occurs during lactation, when menstrua- 
tion is suppressed. On the other hand, menstruation may occur 
independently of ovulation, for it has been known to take place 
after the ovaries and tubes have been removed on both sides. 

Menstruation is the periodical discharge of blood from the 
cavity of the body of the uterus, and occurs throughout the 
child-bearing period (from thirteen to forty-five years of age or 
thereabouts), at regular intervals of about twenty-eight days, 
except during pregnancy and lactation, when it is usually sup- 
pressed entirely. Next to twenty-eight days the most common 
interval is thirty days, and in certain cases the flow appears as 
often as every twenty-one days without any appreciable derange- 
ment of health. 

The essential characteristic of normal menstruation consists 
in a regularity in the interval between the periods, whether it be 
twenty-eight, thirty, or twenty-one days. Any marked irregu- 
larity, or suppression, not due to pregnancy or lactation, indi- 
cates disease of some sort, either local or constitutional. 

Excessive pain before or during the flow, accompanied by 
severe general symptoms, points to some disturbance of the 
pelvic organs, which, in turn, may be due to constitutional 
disease. 

The duration of the flow should be from four to five days 
and the amount of blood lost from five to six ounces. The loss 
of blood is best measured by the number of napkins used, which 
is, commonly, an average of four daily, or twenty in all. While 
many women use more napkins than this, for the sake of cleanli- 
ness and personal comfort, any flow which actually necessitates 
the use of a greater number than twenty in the whole period may 
safely be put down as excessive. 

While regularity in the occurrence of the flow has been men- 



4 o A NURSE'S HANDBOOK OF OBSTETRICS. 

tioned as the chief characteristic of a normal case, it must be 
remembered that, at the beginning and again at the end of men- 
strual life, marked irregularity may persist for from one to 
two years. 

Preceding and accompanying the discharge of blood from 
the uterus there are other symptoms which occur at the men- 
strual periods. In normal, well-developed women, not suffering 
from any constitutional disease, these symptoms may be no more 
than a feeling of weight and congestion in the pelvis, fulness and 
tingling of the breasts, and possibly slight headache or backache. 

In another class of cases, which, unfortunately, constitutes a 
very large proportion of all, the symptoms accompanying the 
flow are far more severe. The sensation of weight and conges- 
tion in the pelvis may give way to pain of a most excruciating 
character, the backache may become almost unbearable, and with 
the intense headache may be associated nausea, or even vomiting 
of a distressing type. 

Women who suffer to this extent are usually pale, thin, and 
anaemic, although they may be stout and plethoric. They com- 
monly lead " hot-house" lives of indolence and luxury, or else 
they go to the opposite extreme and endure poverty and great 
privation. The " hot-house" type, which is the one most likely 
to come under the observation of the nurse, is made up largely 
of women whose early life has been devoid of properly regulated 
out-door exercise and whose later existence has been devoted to 
monotonous in-door pursuits, conducive to morbid introspection, 
or else of those whose only interest has been in the excitement of 
social pleasures with their accompanying late hours and ex- 
hilarating dinners and suppers. 

All marked abnormalities of menstruation are of direct ob- 
stetric importance, for a patient presenting such abnormal symp- 
toms is almost certainly suffering from the effects of a displaced 
or undeveloped uterus, and a deformity or slight contraction of 
the pelvis will be found in a fair proportion of cases. 

The time of life at which menstruation is first established is 
called puberty, and, as has already been stated, it usually occurs 
in this climate at about the thirteenth year. In tropical countries 



PUBERTY. 4 I 

puberty appears at a much earlier age, often as soon as the 
eighth or ninth year, while in the extreme north it is commonly 
delayed until the seventeenth or eighteenth year. 

Accompanying the appearance of the menstrual flow, which, 
as has been said, is apt to be irregular and scanty for the first 
few months, other changes in the child, peculiar to puberty, 
develop. She loses her girlish traits and habits and takes on 
the characteristics of a woman. Her manner becomes more 
restrained, and her liking for childish games and pastimes dis- 
appears. She prefers the society of her elders to that of her 
former comrades, and unless she is carefully watched and wisely 
counselled she is apt to grow moody and lackadaisical. At the 
same time her figure develops into womanly form, — her breasts 
fill out and her hips broaden. In short, almost before her family 
and friends have had time to realize that a change is going on, 
the child has vanished and the woman is in her place. 

This transition period, from girlhood to womanhood, is one 
of the most critical in the life of every woman, and, especially 
among girls of delicate breeding, it must be surrounded by every 
possible safeguard if perfect physical development and future 
health and strength are to be secured. 

Until menstruation is fully established and occurs at regular 
intervals, free from pain or special discomfort, the girl is to be 
treated much as a convalescent patient. Attendance at school is 
to be stopped, and if any studying at all is undertaken it should 
be only of simple subjects, easily mastered and possessing special 
interest. Exercise in the open air should be taken daily in mod- 
erate amount, and a daily bath followed by brisk rubbing, but 
discontinued, of course, during the time of the flow, is of prime 
importance. Plenty of sleep, in a well-ventilated room, is to be 
insisted upon, and meals should be of light but nutritious food 
served at proper intervals. All excitement, late hours, and 
theatre-going must be given up. 

Whenever the flow appears, the first day is to be spent in 
bed, no matter how well the patient may feel, and she is to 
remain in bed until all pain or other discomfort is gone, even 
if it lasts throughout the entire period. 



42 



A NURSE'S HANDBOOK OF OBSTETRICS. 



The bowels are to be kept in good condition, and if simple 
home laxatives do not produce one satisfactory movement daily 
the physician should be notified. 

If these simple rules were observed by every young girl at 
the time of puberty and conscientiously followed out until the 
menstrual function was fully established, there would be far 
fewer complications during pregnancy and labor. 

The amount of study and work that the average school-girl 
undertakes from her thirteenth to her fifteenth year can be much 
more easily and satisfactorily performed at a later period if she 
devotes that part of her life solely to her physical development. 
As a perfect specimen of womanhood she can, in after years, 
more than make up for this slight and temporary interruption of 
her intellectual advancement, while the advantages of an ideal 
physical development, lasting throughout her entire life, should 
of themselves be sufficient reason for the practice of every imagi- 
nable precaution at this most important time of life. 

The end of menstrual life, called the menopause, climacteric, 
or " change of life," occurs at about the forty-third year. At 
this time the periods again become irregular for a few months 
before ceasing entirely, and women are apt to suffer from vague 
forebodings of an indefinite, and often absurd, character. 

The symptoms associated with the menopause have no espe- 
cial obstetric importance except that occasionally a patient will 
at this time attribute the cessation of menstruation to the occur- 
rence of pregnancy, and it is often quite a difficult matter to 
convince her of her error. On this account the nurse will do 
well to regard with some suspicion any claim of pregnancy in 
a woman who has reached a suitable age for the establishment 
of the menopause, but, as pregnancy may occur at this age, she 
must be very careful not to express her opinion in the matter, 
but let a physician decide the question definitely. 



Fetal Development 

The ovum, originating in the ovary and discharged through 
the Graafian follicle at or about the time of menstruation, passes 
into the Fallopian tube, where, if pregnancy is to occur, it meets 
the male element or spermatozoon. The spermatozoon, shaped 




Fig. 17. — Human spermatozoa. (Retzius.) A, front view oi' a spermatozoon ; B, side view; 
h, head ; m, middle piece; /, tail ; e,, end piece. 

like a tadpole, with head and long tail (Fig. 17), penetrates the 
wall of the egg-like ovum and conception has taken place. 

The interior of the ovum, corresponding somewhat to the 
yolk of an egg and now containing the spermatozoon, divides 
into two parts, each part containing half of the yolk and half of 
the spermatozoon. Each of these parts divides in the same way, 
and each subdivision again divides and subdivides until the 
interior of the ovum is filled with a mass of minute divisions of 
the original yolk and spermatozoon (Fig. 18). These are called 
" cells," and keep on dividing and subdividing in the same man- 
ner to form the foetus and its envelopes. As each separate cell 

43 



44 



A NURSE'S HANDBOOK OF OBSTETRICS. 



contains part of the maternal element (ovum) and part of the 
paternal element (spermatozoon), it is not difficult to under- 
stand why the child partakes of the characteristics of both 
father and mother. 




Fig. iS. — First stages of segmentation of the ovum of a rabbit. (Allen Thomson, after 
Edward van Beneden's description.) 



During this process of subdivision of the ovum, which is 
called segmentation, the entire mass passes slowly on through 
the Fallopian tube until it emerges into the cavity of the uterus. 
Once within the cavity, it lodges in one of the folds of the 
mucous lining, usually in the region of the fundus, and the bor- 
ders of this fold reach up around it to hold it firmly and prevent 
its dislodgement (Fig. 19). 

The mucous membrane lining the uterus undergoes certain 
changes at each menstrual period, and, as it was formerly sup- 
posed to be cast off with the menstrual flow and a new mem- 
brane formed before the next period occurred, it was called 
decidna (Latin, deciduus, falling off). It it now understood 
that little or no tissue from the lining of the uterus is lost in 
the monthly discharge, but the old name is still retained, al- 
though the elaborate distinctions between the " decidua of men- 
struation" and the " decidua of pregnancy" are no longer dis- 



THE OVUM. 45 

cussed as formerly. Upon the occurrence of pregnancy there 
can be, of course, no " falling off" of the uterine lining, no 
matter what may once have been thought to have taken place 
at the monthly flow, or the ovum itself would be cast away at 
the same time and abortion or miscarriage would result. 

The uterine lining contains a vast number of little creases 
or folds and the impregnated ovum, after passing from the 
Fallopian tube into the womb, lodges in one of these and be- 
comes securely attached to the mucous membrane, usually near 
the upper part of the organ, as has already been said. Once 
securely fixed at this point, the walls of the fold in which the 
ovum is lodged begin to grow up around it until they meet 
and enclose it as in a shell. This little shell, containing the 
impregnated ovum, is made up of decidua, and there is other 
decidua lining the rest of the uterine cavity upon which this 
" shell" and its contents lie, much as would a wart in the palm 
of the hand when the hand was tightly closed. 

Thus we have, in pregnancy, three kinds of decidua, — (a) 
that upon which the ovum rests as soon as it lodges in the fold 
of the mucous membrane, called decidua serotina; (b) that 
which folds up around the ovum to encapsulate it, called decidua 
reflexa; and (c) that which lines the remainder of the uterine 
cavity, called decidua vera or " true" decidua. 

These terms, " decidua serotina" and " decidua reflexa," date 
back to the time when it was believed that the uterine lining 
was cast off at every menstruation, and before any very clear 
understanding had been reached as to the manner of the forma- 
tion of the decidua of pregnancy. At the present day the ex- 
pressions decidua basilis and decidua capsularis, respectively, 
are undoubtedly in better usage, but as they are not so gen- 
erally accepted they will receive no further notice here. 

As the ovum enlarges, the decidua reflexa also increases in 
size until, at about the fourth month when the embryo entirely 
fills the uterine cavity, it meets and blends with the decidua vera 
at every point. 

On the decidua serotina, or point of attachment between the 
impregnated ovum and the uterine wall, is formed what is known 



4 6 



A NURSE'S HANDBOOK OF OBSTETRICS. 



as the placenta, through which the foetus receives its nourish- 
ment and oxygen from the mother and which will be described 
later. 

The decidna reflexa, both before and after it has blended with 
the decidna vera, forms the outer covering of the amniotic sac, 




Fig. 19. — Uterus with decidua in beginning pregnancy. (Ruge.) o.i., internal os ; o, 
ovum, covered by decidua reflexa ; d, decidua vera. 



or " bag of membranes," which is lined with a transparent mem- 
brane called the amnion and filled with a pale, straw-colored 
liquid, the amniotic fluid or liquor amnii, in which the foetus 
floats. 

Considering, now, the foetus at or near the time of labor, we 
find it floating in a straw-colored liquid, which is contained in 



THE DECIDUA. 



47 



a sac, the " bag of membranes," or amniotic sac, and which lies 
within the uterus and fills it entirely (Fig. 20). 

The function of the amniotic sac is to protect the foetus from 
blows or other injuries that may be inflicted on the mother, while, 
at the same time, allowing it considerable freedom of motion ; 
to provide it with nourishment and oxygen through the placenta ; 
and, at the time of labor, to dilate the neck of the uterus by 
forcing its way down through the internal os and stretching the 
cervix in every direction. 




Fig. 20.— Normal position of foetus in utero. (Garrigues.) Extremities completely 
flexed; occiput presenting-, and back of child to left of mother and directed towards the 
front. (First, or left occipito-anterior, position,—" L. O. A.") 



Except at one point, which corresponds to the point of at- 
tachment of the impregnated ovum to the uterine wall, the 
amniotic sac consists of three layers. The inner, called the 
amnion, which secretes the liquor amnii, is thin and transparent ; 
the middle layer, called the chorion, is thicker and translucent; 
while the outer layer is made up of decidua reHexa and decidua 
vera fused together. 



48 A NURSE'S HANDBOOK OF OBSTETRICS. 

At the point of attachment of the ovum to the uterine wall, 
however, a different formation is found. Instead of a thin, veil- 
like membrane, a thick spongy mass, called the placenta, is de- 
veloped. It, too, is covered on its inner (fetal) surface with 
amnion, under which is a layer of chorion, but its outer surface 
is composed of decidua serotina. 

The placenta (Figs. 21 and 22) is a circular mass about 
eight inches in diameter, one to one and a half pounds in weight, 
and one inch in thickness at its centre, thinning out considerably 
towards the periphery. It forms part of the bag of membranes, 
and may be regarded as a large thickened area in the sac, 
attached firmly to the uterine wall. 

It is made up almost wholly of blood-vessels, which throw 
out loops into the uterine tissue to interlock with somewhat 
similar loops in the vessels of the uterus, but there is no direct 
connection between the uterine and placental vessels and no 
actual interchange of blood. The blood of the foetus is pumped 
by the fetal heart through the placental vessels, and gives up 
its waste products to, and takes on oxygen from, the maternal 
blood, much as the blood of an adult is oxygenated by passing 
through the lungs in vessels that lie closely in contact with the 
air-spaces. This process, by which waste products and oxygen 
can pass from fetal to maternal blood, and vice versa, through 
the walls of the vessels without any actual mingling of the blood 
currents, is called osmosis. 

The placenta and foetus are connected by means of the funis, 
or umbilical cord, usually about twenty inches in length and the 
size of the forefinger. It leaves the placenta at about its centre 
and enters the abdominal wall of the foetus at a point called the 
umbilicus, or " navel," a trifle below the middle of the median 
line in front. 

The placenta is formed during the second month of gesta- 
tion, but is not fully developed until the third month, after which 
it steadily increases in size as pregnancy advances. 

The umbilical cord is formed about the fourth week, and, 
like the placenta, increases in size with the advancement of 
pregnancy. It is made up of two arteries and one large vein, 



THE PLACENTA. 



49 




Fig. 21. — Fetal surface of the placenta. (Garrigues.) The filmy membrane about the 
circumference is the ruptured amniotic sac. 




Fig. 22. — Maternal surface of the placenta. (Garrigues.) 
4 



5o 



A NURSE'S HANDBOOK OF OBSTETRICS. 



which are twisted upon each other, and these are protected by 
a soft, transparent, bluish-white, gelatinous substance called 
" Wharton's jelly." 

During the early months of pregnancy the foetus, or " em- 
bryo," as it is usually called, bears no resemblance whatever 
to the human form. At the end of four weeks the ovum (Fig. 
23) is merely a spongy-looking sphere containing a small, 
curved, gelatinous mass, with no evidence of head or extremities 
(Fig. 24), and if an abortion occurs at this time it is almost 
invariably lost in the discharge of blood. 

By the end of the third month it has increased conside'rably 
in size, being about four inches in length and weighing about 



Fig. 23. — Human ovum at the end of the first month. Actual size. (Wood's Museum, 
Bellevue Hospital, No. 1193.) 

three and one-half ounces (Fig. 25). The head is now devel- 
oped, and is by far the largest part of the foetus, being nearly 
one-third its entire size. The neck and extremities are also 
formed and the fingers are separated. The skin is of a pale 
rose-color and very thin and delicate. The placenta is distinctly 
developed, and the genital organs are formed sufficiently to per- 
mit recognition of the sex. From this time on the embryo is 
called the fcetus. 

Development progresses rapidly as the weeks go by, and at 
the end of the sixth month marked changes have occurred. 
The fcetus is now about twelve inches long and weighs about 



THE FCETUS. 



51 




Fig. 24. — Outline of human embryo of about four weeks. Enlarged four times. (Allen 

Thomson.) 




t 



K 









r iG. 25.- Human foetus at the end of the third month. Three-fifths actual size. 
(Garrigues.) 



52 A NURSE'S HANDBOOK OF OBSTETRICS. 




Fig. 26. — Skeleton of infant at term, showing large head, large anterior fontanelle, 
small thorax, cartilaginous sternum, Jilted pelvis, and bow-legs. Warren Museum, Harvard 
University. (Rotch.) 



THE FCETUS. 



53 



a pound. Faint evidences of the eyelashes and eyebrows have 
appeared, and the skin is darker and firmer. 

During the seventh month development is extremely rapid, 
and by the end of this period the foetus is about fifteen inches 
long and weighs from three to four pounds. The eyelids can 
now be opened, and the skin is firmer, lighter in color than 
before, and covered with a greasy, sebaceous deposit, called 
" vcrnix caseosa" which is most abundant in the folds of the 
integument, and especially in the axillae and groin. This is 
probably the earliest time at which a child can be born with any 
reasonable prospect of living. 

During the eighth month development is slower, and by the 
end of the ninth, or at " full term," the infant is plump, com- 
pletely formed, and ready to perform the functions of respira- 
tion, digestion, and excretion. It is from eighteen to twenty- 
two inches in length and weighs from six and one-half to 
seven and one-half pounds. The nails are fully developed and 
reach the ends of the finger-tips, the hair is long and full, 
and the skin is firm and paler than at any other previous 
time. 

The head of the fully developed foetus (Fig. 26) is still the 
largest part of its body, although it has been growing propor- 
tionately smaller throughout the entire period of gestation. It 
is oval, or egg-shaped, and it is divided into two parts, the 
cranium and the face. 

The cranium (Fig. 27) is the portion possessing the greatest 
obstetric importance, because, if it can pass safely through the 
pelvic canal, there is seldom, if ever, any difficulty in delivering 
the rest of the body. It is made up of eight bones, joined 
together firmly at the base but separated at the vertex, or top 
of the head. The sphenoid, ethmoid, and two temporal bones 
lie at the base of the cranium, and are of no interest to the 
obstetric nurse. 

The frontal, occipital, and two parietal bones are, however, 
of great importance, and form the upper part of the cranium, 
separated at the time of birth by membranous intervals called 
sutures, the intersections of which are termed fontanelles. 



54 



A NURSE'S HANDBOOK OF OBSTETRICS. 




THE FETAL SKULL. 



55 



By means of this formation of the fetal skull the bones can 
overlap each other somewhat during labor and so diminish 
materially the size of the head during its passage through the 
pelvis. This process of overlapping is called " moulding/' and, 
after a long labor with a large child and a snug pelvis, the head 
is often so well moulded that several days elapse before it 
returns to its normal shape. 

The sutures of the cranium are five in all, but those sepa- 
rating the parietal and temporal bones on either side are unim- 
portant, as they cannot be reached by the examining finger 
during labor. 

The coronal suture separates the frontal from the two parie- 
tal bones, the lambdoidal suture separates the occipital from the 
parietal bones, and the sagittal, or " greater suture" begins at 
the base of the nose, divides the frontal bone into two parts, 
crosses the coronal suture, separates the parietal bones from 
each other, and ends at the lambdoidal suture behind. 

The anterior fontanelle, large and diamond-shaped, is at 
the intersection of the sagittal and coronal sutures, while at the 
junction of the sagittal with the lambdoidal suture is the small, 
triangular, posterior fontanelle. 

The sutures and the posterior fontanelle ossify shortly after 
birth, but the anterior fontanelle remains open until the child 
is over a year old, constituting the familiar " soft spot" just 
above the forehead of an infant. 

By feeling one or another of the sutures or fontanelles, and 
considering its relative position in the pelvis, the physician is 
enabled to determine accurately the position of the head at the 
beginning of labor. 

The foetus lies in the uterus in a state of complete flexion. 
Its body is arched forward, its head is bent upon the chest, 
its arms lie close to its body, with the forearms flexed and 
crossed in front. The thighs are flexed upon the body and the 
legs upon the thighs, while the feet are crossed like the hands. 
In nearly all cases the head points downward and the breech 
lies at the fundus. This is probably because the head, being 
the heaviest part of the foetus, would naturally sink to the lowest 
part of the uterus. 



56 A NURSE'S HANDBOOK OF OBSTETRICS. 

The foetus receives its nourishment and oxygen from the 
mother's blood into its own through the medium of the placenta. 
The fetal heart pumps blood through the umbilical cord into 
the placental vessels, which, looping in and out of the uterine 
tissue and lying in close contact with the uterine vessels, per- 
mit an interchange, through their walls, of waste products from 
child to mother and of nourishment and oxygen from mother 
to child. As has been said, this interchange is effected by the 
process of osmosis, and there is no mingling of the two blood- 
currents. In other words, no maternal blood actually goes to 
the fcetus, nor does any fetal blood reach the mother. 

The fetal circulation is so arranged that this passage of 
blood to the placenta through the umbilical arteries and back 
through the umbilical vein is possible up to the time of birth, 
but ceases entirely the moment the child breathes and so begins 
to take its oxygen directly from its own lungs. 

In order to understand, even in a general way, the course 
of the fetal blood-current, it must be borne in mind that, in the 
infant after birth, as in the adult, the venous blood passes from 
the two venae cavae into the right auricle of the heart, thence to 
the right ventricle, and through the pulmonary artery to the 
lungs, where it gives up its waste products and takes on a fresh 
supply of oxygen. After oxygenation the so-called arterial blood 
flows from the lungs, through the pulmonary vein to the left 
auricle, thence to the left ventricle, and out through the aorta, 
to be distributed to all parts of the body and eventually collected, 
as venous blood, in the two venae cavae and discharged again into 
the right auricle (Fig. 28). 

In the fcetus there are certain structures necessary to the 
performance of fetal circulation, but of no use after respiration 
has commenced and the flow of blood through the umbilical and 
placental vessels has ceased. Consequently these structures are 
abandoned as soon as the child cries, and shortly after birth 
they either disappear entirely or are converted into fibrous cords, 
and remain in after life as fetal structures only. 

The most important of these, and the one that must close 
promptly and effectually at birth if the child is to live for any 



FETAL CIRCULATION. 



57 




t I ARTERIAL BLOOD 



VENOUS BLOOD 



Fig. 28.— Diagram of circulation after birth. Adult type. 



58 



A NURSE'S HANDBOOK OF OBSTETRICS. 




| 1 ARTERIAL BLOOD 

\M% VENOUS, BLOOD 

Fig. 29.— Diagram of circulation before birth. Fetal type. 



FETAL CIRCULATION. 59 

length of time, is the foramen ovale, — a valve-like opening 
between the right and left auricles. The others are the ductus 
arteriosus, connecting the aorta and the pulmonary artery; the 
ductus venosus, connecting the umbilical vein and the ascending 
vena cava ; and the two hypogastric arteries, springing from 
the internal iliacs and passing out of the abdomen, through the 
navel, into the cord, where they become the umbilical arteries. 

Keeping in mind the course of the blood-current after birth, 
when these fetal structures have ceased to exist as blood-passages, 
we can trace the fetal circulation from the placenta, where it is 
oxygenated before birth, back to its starting-point (Fig. 29). 

The arterial (oxygenated) blood flows up the cord through 
the umbilical vein and passes into the ascending vena cava, 
partly through the liver but chiefly through the ductus venosus 
which connects these two vessels. It is because of the fact that 
the liver receives a considerable supply of freshly vitalized blood 
direct from the umbilical vein that it is, proportionately, so large 
in the newly born child. 

From the ascending vena cava the current flows into the right 
auricle and directly on to the left auricle through the foramen 
ovale, thence into the left ventricle, and out through the aorta. 
The blood which goes up to the arms and head returns through 
the descending vena cava to the right auricle again, but instead 
of passing through the foramen ovale as before, the current is 
deflected downward into the left ventricle and out through the 
pulmonary artery, partly to the lungs (for purposes of nutri- 
tion only), and partly again into the aorta through the ductus 
arteriosus. 

The blood in the aorta, with the exception of that which goes 
to the head and upper extremities, and which has already been 
accounted for, passes downward to supply the trunk and lower 
limbs. The greater part of this blood finds its way through the 
internal iliacs to the hypogastric arteries, and so back through 
the cord to the placenta, where it is again vitalized ; but a small 
amount passes back into the ascending vena cava, partly through 
the liver and partly from the lower extremities, to mingle with 
fresh blood from the umbilical vein and again make the circuit 
of the entire body. 



60 A NURSE'S HANDBOOK OF OBSTETRICS. 

As soon as the child is born it cries and inflates its lungs. 
This causes the ductus arteriosus to contract, and blood no 
longer passes from the pulmonary artery into the aorta. At 
the same time the foramen ovale closes and the blood from the 
venae cavae, which is discharged into the right auricle, passes 
at once into the right ventricle, to be sent through the pulmonary 
artery to the lungs for oxygenation. 

When the cord is tied and cut the current of blood through 
the umbilical vessels (arteries and vein) ceases and the blood 
is dammed back through the hypogastric arteries to the internal 
iliacs and shut off completely in the umbilical vein and ductus 
venosus. 

These processes, which occur instantaneously, change the 
entire course of the blood-current and convert the fetal circu- 
lation into the ordinary adult type. The foramen ovale remains 
closed and eventually disappears, and the ductus arteriosus, 
ductus venosus, and hypogastric arteries shrivel up and are con- 
verted into fibrous cords in the course of ten or fifteen days. 

When, as occasionally happens, two or more embryos develop 
in the uterus at the same time the condition is known as multiple 
gestation. 

This is of very rare occurrence, twins being encountered but 
once in 90 pregnancies, triplets but once in 8000, and quadruplets 
but once in 370,000. These figures, of course, vary considerably. 
but they serve to show the extreme rarity of multiple concep- 
tions. 

In twin pregnancies the most common combination of sex is 
a boy and a girl : the next in frequency is two boys ; and the 
least common of all is two girls. 

Heredity plays an important part in the causation of twins, 
often making certain families conspicuous on this account, and 
the hereditary trait is most frequently handed down through the 
father. 

Twins are usually due to the fertilization of two separate 
ova, either from the same or from different Graafian follicles, 
but they may result from the double impregnation of a single 
ovum by two spermatozoa or from the complete fusion of a 
single germ. 



MULTIPLE GESTATION. 



61 



Triplets come from the double impregnation or complete 
fusion of one ovum and the simultaneous single fertilization of 
another, while quadruplets may be regarded as double twins. 

In the case of twins it is to be borne in mind that as both 
umbilical cords may come from the same placenta, the maternal 
end of the cord attached to the first-born must be tied securely 
before it is cut, lest the unborn child bleed to death. The nurse, 
from whom skill in ante-partum diagnosis is not to be expected, 
should make it a point to tie securely both the fetal and the ma- 
ternal end of every cord before cutting, in view of the possi- 
bility of the existence of twins. 

The development of the foetus in multiple pregnancies does 
not differ from that of single impregnation, except that the in- 
fants are apt to be small and feeble, usually one being decidedly 
weaker and punier than the other. 



VI 

The Physiology of Pregnancy 

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ABDOMINAL MARKINGS. 



63 




Fig. 30. — Striae gravidarum, or Linese albicantes, showing also abdominal pigmenta- 
tion especially marked around navel, and protrusion of umbilicus. Multigravida at term. 
Twins. 



64 A NURSE'S HANDBOOK OF OBSTETRICS. 

stretching, rupture, and atrophy of the deep connective tissue of 
the skin (Fig. 30). They grow lighter in color after labor has 
taken place, and finally take on the silvery whiteness of cica- 
tricial tissue. In subsequent pregnancies new reddish or bluish 
lines may be found mingled with old silvery white striae. 

The number, size, and distribution of stria gravidarum vary 
exceedingly in different women, and patients are occasionally 
seen in whom there are no such markings whatever, even after 
repeated pregnancies. 

As the striae are due solely to the stretching of the cutis, 
they are not peculiar to pregnancy, but may be found in other 
conditions which cause great abdominal distention, such as 
dropsy and the presence of large tumors of rapid growth. 

Coincident with the uterine and abdominal enlargement the 
umbilicus is pushed upward until, at about the seventh month, its 
depression is completely obliterated and it forms merely a dark- 
ened area in the smooth and tense abdominal wall. Later it is 
raised above the surrounding integument and projects to about 
the size of a hickory-nut. 

While these changes in the uterus and abdomen are going on 
the vagina and external genital organs are being prepared for 
the passage of the foetus at the time of labor. The parts are 
thickened and softened and their vascularity is greatly increased. 
This increase in the blood-supply of the genital canal gives to 
the tissues a dark-violet hue, in great contrast to the ordinary 
pinkish color of the parts, and often described as a valuable 
sign of pregnancy. 

Towards the end of gestation the vaginal secretion is in- 
creased in amount to serve as a lubricant at the time of delivery. 

The changes in the breasts are such as will prepare these 
organs for the performance of nursing, and begin to show them- 
selves shortly after the occurrence of conception (Fig. 31). The 
breasts become larger, firmer, and more prominent, and the 
nipples increase in size, grow sensitive, and are easily stimulated 
to erectility. The pinkish areola about the nipple of the woman 
who has never borne a child grows larger and darker until it 
becomes brown or, in some cases, almost black. This change 



DIGESTIVE DISTURBANCES. 65 

in the color of the tissue surrounding the nipple is most pro- 
nounced in decided brunettes and less marked in women of the 
blonde type. The sebaceous glands which surround the nipple 
to the number of about a dozen, and are known as the " glands 
of Montgomery," become enlarged into little rounded elevations 
under the influence of pregnancy, and are then called the " tu- 
bercles of Montgomery" (see Fig. 36). 

The distention of the skin covering the breasts also causes 
the formation of " striae" similar in every respect to those already 
described as occurring in the abdominal integument. Like the 
abdominal striae, these markings vary greatly in different sub- 
jects and not infrequently are entirely absent. 

After the third month the breasts contain a thin, bluish-white, 
translucent fluid known as " colostrum/' consisting chiefly of 
fat corpuscles, epithelial cells, and " colostrum corpuscles." 
Colostrum is the only substance secreted by the breast until 
about the third day after labor, when the true milk is formed. 
It contains practically no nourishment, but is of value to the 
infant during the early days of its life because of its marked 
laxative effect. 

The blood of the pregnant woman is increased in amount and 
in its watery constituents, while its red cells are proportionately 
diminished. These changes frequently cause disturbances of 
the circulatory apparatus, and the left side of the heart is appre- 
ciably enlarged in order to perform the extra work of pumping 
this increased quantity of blood through the body. 

Palpitation of the heart is not uncommon, and is due, in the 
early months of pregnancy, to sympathetic nervous disturbance, 
and towards the end of gestation to the pressure of the enlarged 
uterus. 

In certain cases the watery constituents of the blood are 
increased to such a degree that marked swelling (oedema) of 
the legs, thighs, and external genitals may occur. This oedema 
must not be confused with that due to kidney disorder, and any 
swelling of the extremities should be reported at once to the 
physician. 

The lungs are subjected, in the later months of pregnancy, 



66 



A NURSE'S HANDBOOK OF OBSTETRICS. 




FIG. 3i.-The breasts of pregnancy. A, A, in a brunette; B, B, in a blonde. At or near 

full term. 



DIGESTIVE DISTURBANCES. 67 

to pressure from the underlying uterus, and the patient may 
suffer severely from cough and dyspneea. Owing to the increase 
in the total quantity of maternal blood, and because of the fact 
that the mother is called upon to oxygenate not only her own 
blood but, by osmosis, that of her infant as well, the work of 
the lungs is markedly increased and the elimination of carbonic 
acid gas is much greater than in the non-pregnant state. 

The digestive, secretive, and excretive organs are likewise 
taxed to a high degree, for the pregnant woman must, in order 
to nourish both her child and herself, form more blood, digest 
more food, and excrete more waste products. After a few weeks 
these increased demands on the digestive organs begin to mani- 
fest themselves by causing nausea and vomiting, and the patient 
is fortunate if these symptoms do not cause her great distress 
up to about the middle of gestation. 

The appetite also is apt to be capricious in the early months, 
and, owing to the nausea, it may be greatly diminished. 

As pregnancy advances and the digestive apparatus seems to 
become accustomed to its new conditions, these disagreeable 
features gradually disappear and the patient usually eats heartily 
and gains in weight and strength. Her increase in flesh is often 
noticeable, and the deposits of fat are most marked about the 
breasts, abdomen, and hips, giving a rounded fulness to her 
figure. 

The body temperature probably undergoes no change during 
pregnancy, although it is said by some writers to rise a fraction 
of a degree towards night. This point is not firmly established, 
and any regular, though slight, evening exacerbation of tempera- 
ture should be reported to the attending physician. 

The skin is affected by an increased activity of the sebaceous 
and sweat-glands and the hair follicles. A marked improvement 
in the growth of the hair is often noticeable at this time, and 
many women whose hair was thin and brittle before the occur- 
rence of conception find it long and luxuriant at the end of the 
puerperium. The increased activity of the sweat-glands is due 
to their efforts to assist the kidneys in the elimination of waste 
material. 



68 



A NURSE'S HANDBOOK OF OBSTETRICS. 



In addition, there are also deposits of pigment in various 
parts of the integument, most noticeable about the nipples and 
umbilicus and along the median line of the abdomen from the 
mons veneris to the navel (Fig. 32). In certain cases, also, 




Fig. 32.— Abdominal pigmentation. Deposits of pigment in median line and protrusion of 
umbilicus clearly shown. Primigravidse at about the eighth month. 

irregular spots or blotches of a muddy brown color, resembling 
large freckles of varying size and shape, appear on the face, and 
dark rings are formed under the eyes. These facial deposits, 
which in rare instances may be distributed over the entire body, 
are known as "chloasmata" (plural of chloasma), and often 
cause the patient great mental distress, but her mind can be re- 
lieved by the assurance that they will disappear after labor, if 
not before. The pigmentation of the breasts and abdomen, how- 
ever, never disappears entirely, though it is usually much less 
pronounced after the birth of the child. 

All of these pigmentary deposits vary exceedingly in size, 
shape, and distribution, and are usually more marked in bru- 
nettes than in blondes. The abdominal and, especially, the mam- 
mary markings are present in almost every case, but the facial 
deposits are of comparatively rare occurrence, especially in their 
exaggerated forms. 



THE URINE OF PREGNANCY. 69 

The pelvis shows certain changes due to pregnancy, which 
are manifested by a thickening and softening of the cartilages 
lining the joints. This, combined with a tipping backward of 
the spinal column and a throwing back of the head and shoulders, 
necessary to enable the woman to maintain her balance in the 
erect posture, giyes to the patient a peculiar " wobbly" gait, 
quite characteristic of pregnancy and especially noticeable in 
short women. 

The urine of pregnancy is decidedly increased in amount, and 
is usually of a pale straw-color and low specific gravity. Owing 
to the pressure on the bladder from the enlarged uterus, and also 
because of the increase in the total quantity of urine to be voided 
in each twenty-four hours, the act of urination is usually very 
frequent and occasionally most uncomfortably so. Traces of 
albumin are to be found at one time or another in the urine of 
practically every pregnant woman, and while, in the majority 
of cases, this albuminuria is purely physiological and transitory, 
it may be of a progressive type and indicate renal disturbance 
of a serious nature. In like manner, glucose (sugar) is to be 
found at times in the urine of pregnancy, and, while its presence 
may be of no especial significance, it should be carefully watched. 

Hence regular and more or less frequent examinations of 
the urine are necessary throughout the entire period of gestation, 
and it is part of the nurse's duty to her patient to see that speci- 
mens are secured at proper intervals and sent to the attending 
physician for analysis. 

In cases where there is a history of previous kidney disease, 
or with patients who have suffered from scarlet fever or diph- 
theria, the importance of regular urinary examinations at fre- 
quent intervals cannot be too strongly emphasized, for, at any 
time under the influence of pregnancy, a latent nephritis may 
light up and assume most dangerous proportions. 

The effect of pregnancy on the nervous system varies greatly, 
and, while some women may entirely escape such manifestations, 
the majority of patients present more or less altered mental and 
emotional characteristics, varying all the way from fretfulness 
and peevishness to actual insanity of a melancholic or even 



jo A NURSE'S HANDBOOK OF OBSTETRICS. 

maniacal type. In rare instances the change is quite to the oppo- 
site extreme, and a woman who is ordinarily of an irritable dis- 
position becomes exceedingly amiable and agreeable. 

The most evenly balanced woman is subject to these emotional 
changes, and it is impossible to foretell how pregnancy will affect 
any given patient, but in general it may be said that the psychical 
factor enters largely into the question, and that the more strongly 
the woman desires a child the more apt will she be to go through 
her pregnancy without disagreeable nervous manifestations. 

Moreover, the higher the patient stands in the social scale 
the more likely is her nervous system to break down under the 
strain of pregnancy, and the nurse who may never have wit- 
nessed any such complications during her hospital training will 
encounter many such women in the private practice of her pro- 
fession. 

It is to be borne in mind that none of the conditions de- 
scribed in this chapter is such as should cause special discomfort 
to a healthy woman whose pregnancy is proceeding in a natural 
manner, and any symptom that becomes unduly prominent should 
be reported to the physician at once. 



VII 

The Disorders of Pregnancy 

The disorders of pregnancy are, in many instances, merely 
exaggerated states of those conditions already described as 
being, in their milder forms, purely physiological and unavoid- 
able. On the other hand, symptoms appear at times which 
must be regarded from the very moment of their onset as un- 
natural and pathological. The properly trained nurse should 
be able to distinguish accurately between conditions which are 
mere exaggerations of true physiological phenomena and those 
which are entirely pathological and inherently dangerous to 
the life or health of the patient. 

Nausea and vomiting, if occurring only in the morning and 
subsiding by about noon, so that during the latter part of the 
day the patient is able to enjoy and retain her food, are to be 
considered as physiological conditions, of importance only as 
they cause discomfort to the woman. This is the usual type 
of the " morning sickness" of pregnancy, and the patient is 
always able to assimilate enough nourishment each afternoon 
and evening to suffice for the entire day. In normal cases these 
symptoms should disappear entirely by about the middle of the 
fourth month, and they call for no medicinal treatment beyond 
the occasional administration of laxatives to keep the bowels 
in good condition. The nurse can, however, do much to make 
the patient comfortable and lessen the annoyance of morning 
sickness by giving a glass of hot milk or a cup of tea or coffee 
with toast or biscuits half an hour before the patient arises. 
This should be taken in the recumbent position, and the woman 
should lie still on her back for a full half-hour afterwards. 
When she attempts to arise she should do so slowly and gradu- 
ally, avoiding any sudden change to the upright posture. The 
morning vomiting almost never begins until the patient gets 
out of bed on her feet, and if the stomach can be induced 

7i 



72 



A NURSE'S HANDBOOK OF OBSTETRICS. 



to retain even a small quantity of food in the early morning 
it will usually continue to do so for the rest of the day. This 
simple procedure, coupled with careful attention to the con- 
dition of the bowels, often affords great relief, and should 
always be given a fair trial. 

In cases which prove more troublesome, without actually 
becoming serious, the writer frequently prescribes ten grains 
of sodium bromide dissolved in one tablespoonful of camphor 
water and given every three or four hours. This remedy is 
perfectly harmless in the proportions named, and while, as a 
rule, it is not wise for the nurse to order drugs on her own 
responsibility, there can be no objection to her availing herself 
of it in certain cases, as, for example, when she is travelling 
with a patient and no physician is obtainable. 

When, however, the vomiting persists throughout the entire 
day and into the night, so that the patient is not only unable to 
retain any nourishment whatever, but loses her sleep as well, 
the condition is wholly different and becomes distinctly patho- 
logical. Such women lose flesh and strength and quickly 
become emaciated to a startling degree. As the condition 
advances they develop fever, the so-called " starvation tempera- 
ture," and unless relief is afforded promptly they lapse into 
the typhoid state and die of exhaustion. This is, of course, 
an extreme type, and one that will rarely be encountered, but 
the passage from the harmless form of vomiting to the variety 
that may properly be termed pernicious is very insidious, and 
the nurse must constantly be on the alert lest her patient retain 
too little nourishment and so begin to lose flesh and strength. 

As a safe rule of guidance, the nurse should regard with 
suspicion any vomiting that persists beyond the noon hour, and 
report the fact to the physician. 

The treatment of the more severe forms of morning sickness 
lies, of course, with the medical attendant, but the nurse must 
never forget that the whole affair is of nervous origin and that 
it is extremely detrimental for her to express before the patient 
the slightest evidence of apprehension as to the prospect of its 
ultimate control. So strongly does this psychical factor enter 



PERNICIOUS VOMITING. 73 

into the causation of the vomiting of pregnancy, of whatever 
type, that it is not unusual for the mere entrance into the 
patient's room of an eminent consulting physician to bring 
about an immediate cessation of the symptoms. 

In severe cases all feeding by mouth is usually stopped and 
rectal medication and alimentation substituted. For drugs, 
nerve sedatives of the bromide class are usually ordered, and 
nutrient enemata should consist of peptonized milk, egg-nog, 
liquid peptonoids, panopepton, or matzoon. 

Before the administration of a nutrient enema the rectum 
should be thoroughly washed out with a hot normal salt solu- 
tion. This not only cleanses the canal and favors absorption, 
but the salt solution itself is taken up in considerable quantity, 
supplying fluid to the tissues and relieving the distressing thirst 
from which the patient always suffers. Not more than eight 
ounces of nourishment should be used at each feeding, and 
it should be at the body temperature and injected very slowly 
and as high up in the canal as possible, preferably in the colon 
itself. As a rule, the rectal feeding should not be given oftener 
than twice daily, and once- in every six hours is the extreme 
limit. 

Exclusive rectal alimentation can never be continued with 
safety for more than two weeks, and if by that time the vomit- 
ing has not been controlled to such a degree that the stomach 
will retain at least part of the required nourishment, the physi- 
cian is justified in adopting more radical measures, which usu- 
ally consist in the prompt termination of the pregnancy. 

There is, unfortunately, a class of women who understand 
full well that the last resort in the treatment of the pernicious 
vomiting of pregnancy is the induction of abortion, and who, 
in their anxiety to avoid having children, deliberately keep up 
and aggravate their symptoms by the surreptitious self-admin- 
istration of emetics. Happily, such women are not often 
encountered, but the nurse as well as the physican must always 
be on guard against the successful practice of such criminal 
imposition. 

Many other methods of treatment have, of course, been ap- 



7 4 A NURSE'S HANDBOOK OF OBSTETRICS. 

plied from time to time for the control of the vomiting of preg- 
nancy, and even such a simple procedure as elevating the 
patient's buttocks to a level above that of her head has been 
known to succeed, but in general any marked vomiting should 
be reported promptly to the physician and the treatment left 
in his hands. 

Almost every drug in the Pharmacopoeia has been sug- 
gested at one time or another as a specific in this condition, but 
the fact remains that no definite plan of action can be outlined 
to fit all cases, and treatment that proves almost miraculously 
successful in one instance will, and often does, fail utterly in 
another. With the general health, and especially the bowels, 
in good condition, the next most important factor in treatment 
is to gain the entire confidence of the patient and imbue her 
mind with the idea that the condition is only temporary, and 
that it will surely be controlled in due course of time. Above 
all else, the subject of vomiting must never be discussed, or 
even mentioned in the presence of the patient, for the mildest 
and most well-intentioned inquiries of relatives at the breakfast 
table will not infrequently precipitate a severe attack of vomit- 
ing that might otherwise have been avoided altogether. In like 
manner the patient should never be asked what she would like 
to eat, or if she feels inclined to partake of food, and the nurse 
must use her wits and ingenuity to learn the caprices of her 
patient's appetite, so that she can, without comment of any sort, 
place before her at proper intervals daintily prepared and tempt- 
ing dishes. 

It is to be distinctly understood that any vomiting persist- 
ing after the fifth month may be of serious import, and that this 
statement applies especially to that which makes its initial ap- 
pearance in the latter half of pregnancy after the ordinary 
" morning sickness" of the early months has ceased. Any such 
late return of vomiting, however slight, should be reported 
at once to the medical attendant, for it is usually due to some 
form of general constitutional poisoning, known as " toxaemia," 
and is often the forerunner of eclampsia. 

Constipation is the usual condition of the bowels during 



CONSTIPATION. 75 

pregnancy, and is due largely to impaired peristaltic motion 
of the intestine caused by pressure from the gravid uterus. 
The nurse should see that at least one satisfactory movement 
occurs daily, and, as a routine, it is well to have the patient 
drink a glass of hot water for this purpose each morning before 
breakfast. The water should be as hot as can be borne, and a 
pinch of salt may be added to give it a taste. 

This simple treatment, combined with a largely farinaceous 
diet, is occasionally all that is necessary, but usually some 
simple laxative is required in addition. The best preparation 
in such cases is the -fluid extract of cascara sagrada, given at 
bedtime in doses of one-half to one teaspoonful. If the bitter 
taste of the plain fluid extract is objectionable to the patient, 
the aromatic extract may be given instead, but it will be neces- 
sary to administer the latter preparation in about double the 
dosage. Starting with half a teaspoonful of the fluid extract 
(or one teaspoonful of the aromatic extract), either pure or in 
water as the patient prefers, the dose may be increased or 
diminished from night to night until the amount necessary to 
secure one daily evacuation is ascertained. 

In addition to this nightly medication, an occasional glass 
of Hunyadi water or of one of the Saratoga waters (Hathorn 
or Congress) may be given before breakfast, and at times a 
glycerin suppository or a soapsuds enema will be indicated. 

Under no circumstances should the patient be overdosed 
with cathartics, and the physician should be consulted if the 
constipation does not yield readily to some such simple plan 
of treatment as the one outlined above. 

Diarrhoea occasionally occurs during pregnancy, and its 
onset should be reported at once to the medical attendant, 
for if it is allowed to persist it may result in a miscarriage, 
either because of severe straining efforts at stool or on ac- 
count of an extension of the existing intestinal inflammation. 

Castor oil, so commonly given at the onset of a simple diar- 
rhoea, cannot be allowed during pregnancy except by direct 
order of the physician, for it is to be remembered that the 
abortifacient properties of this drug are so well marked that 



j6 A NURSE'S HANDBOOK OF OBSTETRICS. 

they have earned for it the unenviable name of " the poor 
woman's ergot." 

Dyspncea (difficult breathing) occasionally results from 
pressure on the diaphragm of the pregnant uterus, and may 
be sufficient, in the last weeks, to interfere considerably with 
the patient's sleep and general comfort. It is not a serious 
condition, but, unfortunately, it cannot be wholly relieved until 
after the birth of the child, when it will disappear spontaneously. 
It is most troublesome when the patient attempts to lie down, 
and her comfort may be greatly enhanced by propping her well 
up in bed with pillows and cushions. In this semi-sitting pos- 
ture she will at least sleep better and longer than with her head 
low. 

Varicose veins may occur in the lower extremities (Fig. 
33), and at times extend up as high as the external genitals or 
even into the pelvis itself. A varicosity is an enlargement in the 
calibre of a vein due to a thinning and stretching of its walls, and 
may be compared roughly to the bulb in the middle of a David- 
son syringe. These distended areas occur at short intervals 
along the course of the vessel, and give it a knotted appearance. 
They are caused by pressure in the pelvis from the enlarged 
uterus, which presses on the great abdominal veins and inter- 
feres with the return of the blood from the lower limbs. Added 
to this primary cause, any debilitated condition of the patient 
favors the formation of varicosities in the veins because of 
the general flabbiness and lack of tone of the tissues. 

Naturally, the greater the pressure in the abdomen the 
greater will be the tendency to this complication, so that in 
twin pregnancies or in cases of contracted pelvis, where the 
gravid uterus is relatively much larger than normal, varices 
are very frequently seen. Also any occupation which keeps 
the woman constantly on her feet in the latter part of preg- 
nancy causes an increase in abdominal pressure and so acts 
as an exciting factor. The most marked case of varicosities 
ever seen by the writer was in the case of a woman who kept 
a small bakery and luncheon-room and attended to her duties 
in the shop up to the hour of her confinement. 



VARICOSE VEINS. JJ 

The first symptom of the development of varices is a dull, 
aching pain in the limbs due to distention of the deep vessels, 
and inspection will show a fine purple net-work of superficial 
veins covering the skin like lace. Later, the true varicosities 




Fig. 33.— Varicosities of the lower extremities. (Bumm.) 

appear, usually first under the bend of the knee, in a tangled 
mass of bluish or purplish veins often as large as a lead-pencil 
and suggesting a strong resemblance to a bunch of fish worms. 
As the condition advances the varicosities extend up and down 
the limb along the course of the vessels, and in severe cases 
affect the veins of the labia majora, the vagina, and the uterus. 
The treatment consists first and chiefly in the prompt 



yS A NURSE'S HANDBOOK OF OBSTETRICS. 

abandonment, at the beginning of pregnancy, of garters, cor- 
sets, and all other articles of clothing that can cause pressure 
at any part of the body. If varicosities develop in spite of this 
precaution, the patient should spend a good part of the time in 
the recumbent position, and when she is on her feet the legs 
should be bandaged firmly from the ankles to the hips or fitted 
with elastic stockings. Where the general condition of the pa- 
tient is below par the physician will prescribe iron or some other 
suitable tonic. Constipation is, of course, to be avoided, as an 
overloaded state of the bowels adds to the existing abdominal 
pressure. Every effort should be made to prevent the develop- 
ment of varices, for if they are once formed they never disappear 
entirely. 

Hemorrhoids (piles) are nothing more than varicosities of 
the veins about the lower end of the rectum and the anus, and 
the little lumps and nodules seen in a mass of hemorrhoids are 
merely the distended portions of the affected vessels. Like 
varicosities in other places, they are due to pressure interfering 
with return venous circulation, and are aggravated by con- 
stipation. They often cause great distress to the patient, and 
their prominent symptom is a constant and painful desire to 
empty the bowel, which is called " rectal tenesmus," and is not 
relieved, but more often increased, by straining efforts at stool. 

The treatment consists in relieving the constipation, in the 
use of hot compresses, and in the application of an ointment 
containing gallic acid, which can be obtained of any druggist, 
without a prescription, under the name of " nut-gall ointment." 
If these measures are not successful the case should be referred 
to the physician, who will doubtless prescribe suppositories con- 
taining opium or morphine. 

(Edema (swelling) of the lower extremities is not of im- 
portance unless it is associated with albuminuria. If it causes 
much discomfort it may be relieved by rest in bed. When the 
swelling extends to the hands or face it is to be regarded with 
great suspicion as a possible forerunner of eclampsia, and the 
appearance of oedema in any part of the body should serve as 
an indication for the immediate examination of the urine. 



AN/EMIA. 



79 



Irritability of the bladder, characterized by frequent and 
often painful efforts at urination ("vesical tenesmus"), may 
occur at any time during pregnancy, but is usually most trouble- 
some in the later weeks. If it cause great discomfort it should 
be reported to the physician, who may be able to relieve it by 
the correction of an abnormal position or presentation of the 
foetus or by the administration of vaginal suppositories con- 
taining opium or belladonna. 

Anaemia, of mild degree, is the normal condition of the blood 
during pregnancy, but at times it becomes sufficiently severe 
to call for the most active treatment. 

In such cases the onset is usually gradual, and unless the 
patient is carefully watched her condition will become truly 
alarming before treatment is begun. 

The symptoms of severe anaemia usually begin with head- 
ache, and the face becomes colorless and puffy. CEdema of 
the lower extremities begins and gradually ascends until it 
covers the entire body, and may even invade the serous cavities. 
The patient now loses flesh and strength rapidly, and suffers 
from sleeplessness, dizziness, headache, dyspnoea, and frequent 
attacks of fainting. 

The treatment, of course, rests entirely with the physician, 
although the nurse can do much to prevent the occurrence of 
this severe type of anaemia by keeping a careful watch over the 
patient's general condition and encouraging her to exercise 
freely in the open air throughout the entire period of gesta- 
tion. 

No woman who sleeps well, has a good appetite for nourish- 
ing food, assimilates properly what she eats, and spends a fair 
portion of the time out of doors is in any danger of becoming 
markedly anaemic. 

Diseases of the heart, and especially affections of the 
mitral valve, are greatly aggravated by pregnancy, and their 
fatal termination is often hastened from this cause. 

If the patient has placed herself under medical care at the 
beginning of gestation, and if the physician has made a proper 
and thorough examination of all her organs at this time, he will 



8o A NURSE'S HANDBOOK OF OBSTETRICS. 

be in a position to administer such treatment as may be neces- 
sary. The only thing the nurse can do, when it seems to her 
probable that the heart is affected, is to report the matter at 
once to the medical attendant. Personally, the writer believes 
that these patients should not be allowed to go on in the preg- 
nant state, but that abortion should be induced at the earliest 
opportunity after a positive diagnosis has been made. 

Ascites {dropsy) may affect the extremities and even invade 
the pleural and peritoneal cavities. It is due to the altered 
condition of the blood, and the treatment, which should be 
wholly in the hands of the physician, consists mainly in the 
relief of the anaemia, the administration of diuretics, rest in 
bed, and milk diet. 

Ptyalism, or salivation, while one of the rarer complications 
of pregnancy, is most annoying to the patient and very stub- 
born in responding to treatment. It is due entirely to altered 
enervation, and is characterized by an enormously increased 
secretion of saliva, so that the patient drools continually. 
Women have been known to discharge as much as two quarts 
of saliva daily from this cause. 

Associated with ptyalism is occasionally seen an excessive 
secretion of tears, and the face becomes swollen and eczematous 
from being constantly bathed in moisture. 

This complication, if it occurs at all, usually appears in 
the early months of pregnancy, and, fortunately, is inclined to 
cease spontaneously. It is seen in highly nervous women of 
low vitality and is apt to cause great mental depression and 
interfere with nutrition. 

The treatment should be relegated to the physician, and con- 
sists in building up the general health with iron and arsenic and 
in the use of astringent mouth-washes accompanied by atropine 
and bromides, or chloral internally. The treatment is very 
unsatisfactory and the condition is a most disagreable one, not 
only for the patient, but for the physician and nurse as well. 

Insomnia often proves troublesome, and is best relieved by 
strict hygienic methods, open-air exercise, and massage, sup- 
plemented by alcohol rubbing after the patient has retired for 



COUGH AND PALPITATION. 8l 

the night. The sleeping-room should, if possible, be large and 
well ventilated, and so situated that the patient will not be sub- 
jected to any disturbing influences. 

If these measures do not enable her to secure a proper 
amount of natural and refreshing sleep the physician should 
be consulted, and will doubtless order trional, sulfonal, or some 
similar drug. Under no circumstances should opium or mor- 
phine ever be administered in these cases. 

Palpitation of the heart and syncope (fainting) are of 
no consequence unless it can be shown that they are associated 
with, and due to, some organic disease. As a rule, they are 
purely neurotic manifestations, and usually occur in the early 
part of a first pregnancy, and when the patient is in a hot, 
crowded, and badly ventilated room. So well is this tendency 
to faintness understood by the majority of women, that many 
significant glances are exchanged when a bride of a few months 
suddenly grows dizzy and has to be assisted from a theatre, 
ball-room, or other crowded assembly. 

Neuralgia and headache occurring during pregnancy 
should be carefully investigated by the physician, and the nurse 
is to be cautioned against the indiscriminate use of the various 
popular remedies for these conditions. 

Neuralgia, if facial, may be due to affections of the teeth, 
which require the attention of the dentist, and headache, while 
possibly of purely nervous origin, may be a symptom of severe 
constitutional disease. 

In any event, it is safer for the nurse to refer these appar- 
ently trivial symptoms to the medical attendant than to attempt 
their treatment herself. 

Paralysis occurs in certain cases, and may appear either 
before or after delivery. It may be due to uraemia, to cerebral 
congestion, or even to purely neurotic causes. Fortunately its 
outcome is usually favorable, and the treatment, of course, rests 
entirely with the physician. 

Cough, unless due to a distinct bronchitis, is ordinarily of 
reflex origin and is unimportant. In the last months of preg- 
nancy it may be due to direct pressure of the gravid uterus. 

6 



82 A NURSE'S HANDBOOK OF OBSTETRICS. 

Leucorrhcea ("whites") occurs frequently in pregnancy, 
especially if the patient is debilitated and anaemic, and is char- 
acterized by a more or less profuse mucous discharge from the 
vagina. It is often relieved by hot vaginal douches of a solu- 
tion of borax (one tablespoonful to the quart), given twice 
daily, — night and morning. The patient should lie on her back 
while taking the douche, so that the solution will reach every 
part of the vaginal canal, and at least two quarts, as hot as 
can be borne comfortably, should be used. 

The nurse must keep in mind, however, the possibility of 
irritating the uterine muscle to contraction by the use of the 
douche and so causing a miscarriage. This is not likely to 
happen unless the douche is too hot or administered with too 
much force, but at the first appearance of pain, or even " bear- 
ing-down" sensations in the lower abdomen the irrigation should 
be discontinued at once, the patient kept quietly in bed, and the 
matter reported to the physician without delay. If this treat- 
ment is not successful, he may find, on examination, erosions of 
the cervix or other causes sufficient to keep up the discharge. 

Pruritus (itching), when confined to the neighborhood of 
the vulva, is usually due to a coexisting leucorrhcea, and dis- 
appears when the leucorrhcea is cured. It may be relieved by 
hot applications or by the use of some preparation containing 
naphthol, such as " resinol ointment." 

When the pruritus is general and covers the entire body it 
is almost always neurotic in character, though it may be due 
to a gouty diathesis or to diabetes. The treatment in such cases 
should be in the hands of the physician, and usually consists 
of rest in bed, regulated diet, the use of bromides in large doses, 
and the practice of thorough cleanliness, which applies to all 
degrees of pruritus, however slight. If the patient is gouty 
or is suffering from diabetes, these conditions will, of course, 
receive appropriate treatment. 

Chorea, popularly known as " St. Anthony's," " St. John's," 
or " St. Vitus's" dance, is, fortunately, one of the rarest com- 
plications of pregnancy, for it is one of the most serious. It 
usually occurs in the early months of first pregnancies in very 



ALBUMINURIA. 83 

young women, though it may develop at any time. As a rule, 
the history will show that the patient has suffered previously 
with the disease. 

It may begin suddenly or insidiously, and is characterized 
by involuntary movements, or twitchings, of the arms and legs, 
which gradually become more and more marked and extend 
to other groups of muscles. There are exacerbations and re- 
missions of the disease, and the movements regularly cease 
during sleep, to reappear again when the patient wakes. When 
the disease develops early in pregnancy the patient usually 
aborts, and in many cases it is necessary to induce abortion in 
order to save her life. 

Any symptoms suggesting chorea should be reported to the 
physician without delay. 

Displacements of the uterus may be of old standing or 
may occur after pregnancy is established. The symptoms of all 
types of displacement are practically the same, so far as the 
nurse is concerned, and consist chiefly in marked irritability 
of the bladder, excessive constipation, pains in the back and 
loins, and a feeling of weight and " bearing down" in the pel- 
vis. Any such combination of symptoms should be reported 
promptly to the medical attendant, in order that he may cor- 
rect the malposition before the pregnancy is too far advanced. 

Albuminuria, complicating pregnancy, may be one of sev- 
eral types, and may occur as early as the third month, although 
it usually makes its first appearance at about the sixth month. 

The diagnostic and only positive symptom is, of course, the 
presence of albumin in the urine, which should be discovered 
by the physician in the course of his regular urinary examina- 
tions. In properly conducted cases, where analyses of the urine 
are made systematically and at stated intervals, the discovery 
of albumin will be made before any other marked symptoms 
develop, and it often happens that suitable treatment can be 
instituted with sufficient promptness to ward off the impending 
attack. Hence it is of the utmost importance for the nurse to 
attend carefully to the collecting of specimens of urine at regu- 
lar times and forwarding them to the physician for analysis. 



84 A NURSE'S HANDBOOK OF OBSTETRICS. 

In neglected cases the patient becomes anaemic, suffers from 
headache, which is chiefly frontal, and develops oedema, first 
of the ankles and legs, and later of the face and upper ex- 
tremities. Ringing in the ears and dizziness soon become annoy- 
ing symptoms, and disturbances of sight, such as double vision 
and the appearance of spots floating before the eyes, occur and 
increase as the albuminuria becomes more marked. In severe 
cases actual blindness may occur. 

The urine becomes high-colored and scanty and the pulse 
is hard, small, and rapid. 

Vomiting persists throughout the entire day, and is espe- 
cially significant in women whose ordinary " morning sick- 
ness" has ceased. 

In this disturbed state of the digestive system a slight attack 
of acute indigestion or the occurrence of any other ordinarily 
trivial disorder is enough to precipitate an eclamptic seizure. 
A woman in such condition is on the very brink of disaster, 
and the nurse should send at once for the physician,' and while 
awaiting his coming put the patient in bed on an exclusive diet 
of skimmed milk and move the bowels freely with dessert- 
spoonful doses of a saturated solution of Rochelle salt, given 
every fifteen minutes until free catharsis is established. 

Eclampsia is a disease of pregnancy characterized by the 
occurrence of convulsions resembling somewhat those of epi- 
lepsy, and appearing, usually, late in pregnancy just at the 
onset of labor. It may develop, however, at any time during 
the last three months of utero-gestation, during labor itself, or, 
rarely, after labor has taken place. 

The exact cause of eclampsia is not definitely understood, 
but it is safe to say that it is largely dependent upon deficient 
elimination of waste products from the maternal organism. Its 
threatened onset is indicated by the presence of albumin in the 
urine, by insufficient excretion of urea, or by both of these 
symptoms together. 

The premonitory symptoms are those which have just been 
described as characteristic of albuminuria. 

Eclampsia is very dangerous to the mother and almost uni- 



ECLAMPSIA. 85 

formly fatal to the child, and these facts are all the more lament- 
able when it is remembered that, under proper management and 
with careful attention to diet and urinary examinations, the dis- 
ease should be a wholly preventable complication. 

Carelessness in the management of pregnancy and neglect 
of the necessary urinary analyses are, unfortunately, so much 
more often the rule than the exception that, although the writer 
has never lost a mother from eclampsia in his own practice, 
he knows of no less than eight deaths from this cause alone, 
and within the past six years, among his own circle of friends 
and acquaintances. Of these, one woman was a physician her- 
self, and another, the mother of several children, had suffered 
from marked premonitory symptoms of eclampsia in all of her 
previous pregnancies, in spite of which no urinary examinations 
whatever were made by her physician and no special diet or 
treatment was given her. 

Such lack of management is nothing less than criminal, and 
the writer hopes and believes that no reader of this book will 
allow any pregnant woman, no matter how well she may appear 
to be, to go through her pregnancy without proper urinary 
analyses, at least during the last three months. 

After the woman has suffered from albuminuria, and has 
shown its characteristic symptoms for a varying period, she 
may j if the case has not been treated, have a miscarriage. This 
seems to be an effort on the part of nature to relieve her con- 
dition, for by the death of the child and its expulsion from her 
body the strain on her eliminative organs is lessened at least 
to the extent that she no longer has to excrete the waste prod- 
ucts of the foetus. More frequently, however, even if the child 
dies and an attempt at miscarriage occurs, she will pass into 
the eclamptic state and have the characteristic convulsions of 
the disease. 

One attack is practically like another. The patient first 
complains of dizziness, and then everything grows black before 
her eyes. Her hands are clinched, with the thumbs drawn in ; 
her head is drawn backward or to one side ; her face is deathly 
pale; the corners of her mouth are drawn down, and the eyes, 



86 A NURSE'S HANDBOOK OF OBSTETRICS. 

open but rolled upward so that only the " whites" are visible, 
give to the countenance a particularly ghastly appearance. Now 
the large vessels in the neck begin to pulsate violently, the face 
grows gradually more and more cyanotic until it becomes almost 
black, and the glottis closes, causing respiration to stop. 

In this condition the woman remains for from ten to twenty 
seconds, in a state of complete rigidity, after which, if death 
does not occur, her muscles gradually relax. Respiration now 
becomes rapid ; she froths at the mouth, and may expel some 
blood if she has bitten her tongue ; her arms and legs begin to 
twitch, and soon her entire body is in a state of violent con- 
vulsion. After three or four minutes this gradually ceases and 
the woman passes into a condition of coma, from which she 
emerges in a few minutes with no distinct recollection of what 
has taken place. In severe cases the coma may grow deeper 
and deeper until death occurs, or she may pass directly from 
one convulsion to another without regaining consciousness be- 
tween the attacks. 

If the nurse first sees a patient on the occasion of the occur- 
rence of an eclamptic convulsion it will be necessary for her to 
make a diagnosis of the cause of the spasm, in order that she 
may proceed intelligently. 

Practically the only conditions that might be confused with 
eclampsia are epilepsy and hysteria, and if the following points 
are borne in mind the nurse will have little difficulty in arriving 
at a correct opinion. 

Eclampsia occurs in a woman who is pregnant at least six 
months. She has suffered during her pregnancy from the symp- 
toms of albuminuria. Her face is swollen and her entire body is 
cedematous and puffy. Her friends will tell of her headache, 
vomiting, visual disturbances, and the like, and often inquiry will 
reveal the sad fact that her physician (if she has one) has not 
made any urinary examinations or ordered any special diet for 
her. 

Her urine will be scanty and highly colored, and if a little 
is placed in a teaspoon and boiled over the flame of a match 
or gas-jet it will turn white and often solid from the coagula- 



ECLAMPSIA. 87 

tion of albumin. This test is simple, quick, and absolutely con- 
clusive, for, while there may have been little or no albumen in 
the specimen prior to the onset of the attack, it is sure to be 
present in large amount before many convulsions have occurred. 
The author can see no objection to the nurse's availing herself 
of this means of diagnosis unless the physician is close at hand 
and his presence can be secured without delay. If he has to 
be summoned from a distance, a positive report as to the highly 
albuminous state of the urine might be of value to him in making 
his preparations for the treatment of the case, while such knowl- 
edge would certainly aid the nurse in her management of the 
patient while awaiting the arrival of the medical attendant. As 
she comes out of one convulsion she may pass almost at once 
into another, and, even without a thermometer, it will be evi- 
dent that she has considerable fever. She may have only one 
or two attacks and die, or miscarry and recover, or she may 
have fifty or sixty at intervals of from a few minutes to a few 
hours, any one of which may prove fatal. 

Epilepsy occurs independently of utero- gestation, and if the 
woman chances to be pregnant it is merely a coincidence. The 
convulsion is generally ushered in with an outcry, and after it 
is over the patient passes into a sound sleep which may last 
for an hour or more. The attack will not be repeated for days, 
at least, and often it will be weeks or even months before another 
seizure occurs. There are none of the premonitory symptoms 
of albuminuria, and the history will show that the patient has 
long been subject to similar attacks. The nurse must, of course, 
be on her guard against those rare cases in which eclampsia 
occurs in a patient known to be an epileptic. The history of the 
albuminuria and the time of the attack {daring the last three 
months of pregnancy) , together with the recurrence of the con- 
vulsions at short intervals, the appearance of the patient, and 
the presence of fever, should be enough to settle the question. 

Hysteria, like epilepsy, occurs independently of pregnancy, 
and if it happens that the woman is pregnant the hysterical 
attack may occur at any period of gestation. The convulsion of 
hysteria is not as severe as that of epilepsy or eclampsia, the 



88 A NURSE'S HANDBOOK OF OBSTETRICS. 

patient never loses consciousness completely, fever is not present, 
and the pulse and respiration are normal or nearly so, and the 
urine, instead of being scanty, concentrated, highly colored, and 
albuminous, is pale, of low specific gravity, and excreted in large 
quantity. 

It is, of course, to be understood that any convulsion occur- 
ring during pregnancy is a sufficiently important matter to war- 
rant the nurse in sending at once for the physician, and if the 
immediate services of the regular medical attendant cannot be 
secured she should lose no time in summoning the nearest avail- 
able practitioner. 

The treatment of eclampsia begins primarily with those pre- 
ventive measures which should be instituted by the physician 
as soon as the pregnant woman comes under his professional 
care. These consist largely in the adoption of a proper hygienic 
regime which provides for a nourishing diet with the reduction 
of red meat to once daily, the careful regulation of the bowels, 
the practice of daily bathing to keep the skin in good working 
order, the indulgence in regular out-of-door exercise, and the 
daily ingestion of at least two quarts of pure water to act as a 
diuretic and otherwise " flush out" the system. When these 
measures are carefully followed, and the urine is examined at 
stated intervals for evidences of albuminuria, it should always 
be possible to avert a threatened eclamptic attack. Unfortu- 
nately, this plan can be put in operation only when the patient 
comes under observation at a comparatively early period of 
pregnancy, and in many cases the nurse will not be called to a 
case until shortly before labor. 

Her first duty, under these circumstances, will be to ascertain 
if the patient's pregnancy has been properly managed and if the 
necessary urinary examinations have been made. This inquiry 
can always be conducted in a tactful way that will cast no reflec- 
tion on the behavior of the attending physician, and if the nurse 
finds that the proper precautions have not been taken she is 
perfectly justified in making such suggestions as may be indi- 
cated concerning diet, exercise, and the like, and in securing a 
specimen of urine and sending it to the physician for analysis. 



HEMORRHAGE. 89 

Moreover, during the last two months of pregnancy she should 
send a specimen of urine once a week to the medical attendant, 
whether it is asked for or not. This should be done entirely as 
a matter of course, for, in the light of modern obstetrics, no phy- 
sician would dare to find fault with such a procedure even if he 
belonged to that, happily small, class of men who do not bother 
to make urinary analyses at these times. If the patient shows 
any general symptoms of threatened eclampsia, such as head- 
ache, visual disturbances, severe vomiting, and marked oedema, 
the physician should be sent for at once and his attention ex- 
plicitly directed to her condition. 

Occasionally the nurse will encounter the patient for the first 
time when she is in a convulsion, or the woman will have an 
eclamptic seizure shortly after the nurse's arrival or at some 
other time when there is no physician at hand. 

After sending at once for the nearest medical man and as- 
suring herself, from the character of the convulsion, the his- 
tory of the case, the bloated appearance of the patient, and 
the albuminous state of the urine, that the attack is really due 
to eclampsia, the nurse may proceed as follows until assist- 
ance arrives. Let the patient lie where she is, whether it be 
in bed or on the floor, only moving her enough to place her 
in a reasonably comfortable position ; insist upon absolute quiet 
in the room and the avoidance of all excitement ; if chloroform 
is to be had, administer it as for a surgical operation until the 
convulsion has ceased, and while the patient is under the in- 
fluence of the anaesthetic remove all her clothing, cutting the 
garments with scissors, and wrap her entire body (arms and 
legs separately) in a hot wet pack and cover her with warm 
blankets ; empty the bladder with the catheter, disturbing the 
patient as little as possible ; as soon as she can swallow give two 
drops of croton oil in one teaspoonful of sweet oil, if it can be 
obtained; whether the croton oil is given or not, make a satu- 
rated solution of Rochelle salt and give a dessert-spoonful every 
fifteen minutes until the bowels move freely. When the con- 
vulsion ceases insist upon absolute quiet, and do not allow so 
much as a whisper in the room ; disturb the patient as little as 



90 A NURSE'S HANDBOOK OF OBSTETRICS. 

possible and only for the necessary purposes mentioned above; 
under no circumstances attempt to change her position or put 
her in bed ; keep the chloroform constantly at hand and 

BEGIN TO ADMINISTER IT THE MOMENT THE NEXT CONVULSION 

starts. If the child is born and is alive, tie and cut the cord 
and remove it to another room ; if it is dead, leave it alone, 
to avoid disturbing the patient, but in any case keep a hand 
on the fundus, under the hot pack, as a preventive against 
hemorrhage. If there is bound to be a considerable delay in 
securing the attendance of a physician, get thirty grains of 
chloral hydrate and forty grains of sodium bromide and give 
it by rectum. Beyond this : 

Darken the room. 

Maintain absolute quiet. 

Keep up the hot pack. 

Do not disturb the patient under any circumstances. 

Give chloroform whenever a convulsion occurs. 

Secure medical aid as soon as possible. 

Wait till the physician arrives before doing anything else. 

Do NOT LOSE YOUR HEAD. 

Hemorrhage from the uterus may occur at any time during 
pregnancy, and while it may be due to high arterial tension or 
to erosions or ulcers of the cervix, and so be of no special 
consequence, it may, on the other hand, be of serious import; 
and all attacks of bleeding should be reported at once to the 
physician. 

In the early months of pregnancy hemorrhage may be due to 
a beginning abortion or the case may be one of ectopic gestation. 
In the later months the bleeding may indicate placenta praevia or 
be due to the separation of a normally situated placenta from 
the uterine wall. These four conditions will be described in 
detail later on, but so far as the nurse is concerned the general 
treatment of hemorrhage occurring during pregnancy is the 
same in every case: Send at once for the physician; put the 
patient in bed and make her lie still on her back ; reassure her 
in every way possible, and avoid all noise and every suspicion 
of excitement on the part of her friends and relatives ; if she 



ECTOPIC PREGNANCY 



91 



is very nervous or if the hemorrhage seems at all severe, give 
one-sixth grain of morphine hypodermically. 

If the bleeding continues, a sharp watch must be kept for 
symptoms of acute anaemia, and it may be necessary to send for 
the nearest physician available instead of waiting for the arrival 
of the regular medical attendant. When the blood escapes into 
the bed, as in the case of placenta prsevia, the amount of the 
flow should be enough to indicate the proper course to pursue, 
but it must be remembered that in certain instances, as, for 
example, when a normally situated placenta becomes detached 
from the uterus, the woman may bleed to death inside of her 
own body and little or no blood escape from the vagina (see 
Fig. 103). In such a case the symptoms indicative of danger 
would be those of severe hemorrhage from any other cause. 

The patient would be pale, and her pallor would increase as 
the bleeding continued ; she would be extremely nervous and 
restless, and her face, bathed in a cold sweat, would have an 
anxious and " wild" expression ; her pulse would grow more 
and more rapid and feeble, and finally would disappear entirely 
at the wrist ; her thirst would be extreme, and she would soon 
complain of ringing in the ears, dizziness, spots before the eyes, 
and at last total blindness ; towards the end would be seen that 
horrible condition known as " air hunger," in which the patient 
literally tries to bite the air as she w T ould a solid substance, so 
great is her need of oxygen. 

Under these circumstances the nurse can do nothing beyond 
getting medical aid as soon as possible and preparing for the 
probability of a surgical operation, with plenty of hot water and 
hot, sterile, normal salt solution for infusion. 

Pain in the region of the uterus may be merely neuralgic in 
character and of no consequence beyond the discomfort that it 
causes, but its occurrence should always be reported to the 
medical attendant, as it is one of the symptoms of abortion, of 
ectopic gestation, of concealed hemorrhage, and of many of the 
diseases that may complicate pregnancy, such as appendicitis 
and various other disturbances of the abdominal organs. 

Ectopic gestation, occasionallv and incorrectlv termed 



9 2 



A NURSE'S HANDBOOK OF OBSTETRICS. 



" extra-uterine pregnancy," means, literally, a pregnancy that is 
" out of place." In the chapter on Fetal Development it was 
said that the ovum is usually impregnated by the male element 
while it is still in the Fallopian tube, after which it passes on into 
the uterus. If, now, anything occurs to prevent its passage into 
the uterine cavity, it will either develop where it is or else, in 
very rare instances, fall out of the open trumpet-shaped end of 
the tube and develop in the cavity of the abdomen. If its prog- 
ress towards the uterus were not interfered with until it reached 
that portion of the tube which lies within the uterine wall, it 
would be in the uterus, although decidedly ectopic or " out of 
place," which explains the incorrectness of the general term 
" extra-uterine pregnancy." 

This accident may be caused by a narrowing of the tube due 
to a constriction within itself; to folds or twists of the tube 
which may be the result of accident or disease ; to pressure from 
pelvic organs or tumors ; or it may occur with a very long tube 
or when the impregnation takes place close to the ovarian ex- 
tremity, so that before the ovum reaches the uterus it has 
developed to such a size that it is too large for the canal through 
which it is supposed to travel. 

In any event it becomes firmly lodged at some point and 
development proceeds, up to a certain stage, as though it were 
safe within the uterine cavity. 

The most common form of ectopic gestation is that which 
goes on in the tube itself, and is called " tubal pregnancy" (Fig. 
34) ; the next most frequent type occurs in that portion of the 
tube which lies within the uterine wall, and is termed " inter- 
stitial pregnancy;" and the rarest form of all is known as "ab- 
dominal pregnancy," in which the ovum develops in the abdomi- 
nal cavity. Neither tubal nor interstitial pregnancy ever goes on 
to the full development of a living child, but occasionally, when 
the ovum falls into the cavity of the abdomen, the placenta 
attaches itself to some viscus and the fcetus develops to full 
term and is removed by abdominal section. 

In all cases of ectopic gestation the woman exhibits, to a 
certain degree, the usual early symptoms of pregnancy, and, as 



ECTOPIC PREGNANCY. 



93 



a rule, regards herself as being normally with child. The uterus 
enlarges somewhat, the irritability of the bladder and the breast 
symptoms appear, and the patient suffers more or less from 
" morning sickness." Her menstruation may cease entirely, but 
there is usually a slight flow at each monthly period due to con- 
gestion of the lining membrane of the uterus. This may be only 
enough to stain the napkin for one day, and although such a 
" show" may occur in the early part of a normal pregnancy, it 
is entirely unnatural and sufficiently suspicious to warrant the 




Fig; 34.— Ectopic gestation. Tubal variety, ruptured at the end of the third month : 
A, uterus from behind with several small fibroid tumors in its wall; B, right ovary; C, 
ruptured tube ; D, left ovary ; E, foetus. 

nurse in sending for the physician or at least advising him of 
its appearance. 

As the ectopic gestation advances there will be considerable 
pain of a sharp, shooting character on the side of the affected 
tube and extending down the leg. This pain is due to the 
stretching of the tissues of the tube or uterine wall, and any such 
combination of pain and slight bleeding should be brought to 
the notice of the medical attendant without delay. 

In abdominal pregnancy the condition may not be recognized 



94 A NURSE'S HANDBOOK OF OBSTETRICS. 

until the case has gone on to full term, when, as labor does not 
occur, a careful examination will disclose the true state of affairs. 
In unrecognized abdominal pregnancy the child will die, and 
may cause the death of the mother from peritonitis, or it may 
become mummified and remain in the belly indefinitely or else 
adhere to the abdominal wall and eventually slough out in the 
form of an abscess. 

Cases of tubal and interstitial pregnancy, unless recognized 
and operated upon, will rupture into the abdomen sooner or later 
(usually between the first and third months), and the patient 
may bleed to death or die of peritonitis or shock. 

A ruptured ectopic sac would be diagnosed by the history of 
the early symptoms of pregnancy, the excruciating pain at the 
time of the rupture, the occurrence of collapse, and the rapid 
onset of signs of severe internal bleeding. 

The nurse can only send at once for surgical aid, keep the 
patient perfectly quiet, and prepare for an abdominal section. 

While it is possible that the hemorrhage will stop and the 
products of conception be absorbed, the bleeding is usually very 
severe, and only the most energetic action succeeds in saving 
the life of the patient. 

Placenta previa (Fig. 35) signifies an attachment of the 
placenta directly over, or in the immediate neighborhood of, the 
cervix instead of at its usual site near the fundus of the uterus. 
When the placenta completely covers the internal os the condi- 
tion is known as " central placenta prcuvia;" when merely the 
edge of the placenta extends over the opening it is termed " mar- 
ginal placenta prccvia;" and when the placenta is simply attached 
low down on the uterine wall, near the os but not overlapping it, 
it is called " lateral placenta prcevia." 

In any case the condition forms a distinct obstruction to de- 
livery, and the first symptom is a sudden discharge of bright red 
blood without any pain and apparently for no particular reason. 
The first hemorrhage is rarely fatal, but any subsequent one may 
result in the death of the mother before any surgical assistance 
can be obtained. At the first appearance of bleeding of this 
character the nurse should send the patient to bed, give one- 



PLACENTA PR/EVIA. 



95 



sixth grain of morphine hypodermically, summon the physician, 
and prepare for an immediate operative delivery, — usually a ver- 
sion. It is needless to say that all preparations for labor should 
be made without the patient's knowledge, to avoid the possi- 



bility of causing her any alarm. 






Fig. 35. — Placental attachment. A, normal attachment at the fundus; B, lateral placenta 
prsevia ; C, marginal placenta praevia; D, complete, or central, placenta praevia. 

Hemorrhage due to the detachment of a normally situated 
placenta may show itself externally or it may be entirely con- 
cealed, the blood remaining in the uterus and finding room for 
itself by collecting between the fetal sac and the uterine wall (see 
Fig. 103). In such a case the only symptoms would be those of 
severe internal hemorrhage already described, together with 
excruciating pain located at the point of placental separation. 
These cases of concealed hemorrhage are often very difficult to 



g6 A NURSE'S HANDBOOK OF OBSTETRICS. 

diagnose, but the nurse would at least know that something 
serious was the matter, and in putting the patient to bed, giving 
morphine for the pain, and sending at once for the physician she 
would relieve herself of further responsibility. The symptoms 
of concealed hemorrhage from placental separation are practi- 
cally the same as those caused by rupture of the uterus, but when 
it is remembered that the placental detachment always occurs 
before, and the rupture of the uterus during, labor, it will not 
be a difficult matter to distinguish between the two conditions. 

Nose-Bleed occasionally occurs late in pregnancy or early 
in labor, and is due to the existing hydremic condition of the 
blood, coupled with a congested state of the nasal mucosa. It 
is seldom troublesome, but, in certain rare cases, it proves very 
intractable, and may persist until the patient loses an alarming 
quantity of blood. Such cases are, of course, very unusual, 
but the possibility of their occurrence should be kept in mind, 
and any profuse hemorrhage from the nose should be reported 
to the physician. 

Slight hemorrhages from the stomach or lungs, also due to 
the existing hydremia and from areas of local congestion, are 
occasionally met with late in pregnancy, and, unless it can be 
shown that they are due to other causes, such as a gastric ulcer 
or puLnonary tuberculosis, they are seldom of any moment. 
They are, however, usually more alarming to the patient than 
would be a really serious nose-bleed, and, of course, they should 
be reported to the medical attendant at once. While awaiting his 
arrival or advice the patient should lie quietly on her back and 
take small bits of cracked ice at frequent intervals. 

The eruptive fevers, when affecting a pregnant woman, 
are always exceptionally severe, and if the temperature is at all 
high, abortion or miscarriage is almost certain to occur. 

Scarlet fever is particularly fatal during pregnancy, and 
very little hope can be offered to the woman who contracts the 
disease at this time. 

Pneumonia in pregnancy is usually very fatal to both mother 
and child, although, when abortion occurs, as it often does, the 
maternal chances are somewhat improved. 



CONCEALED HEMORRHAGE. 97 

Tuberculosis shows apparent improvement during preg- 
nancy, but, as a matter of fact, its fatal outcome is probably 
hastened, for the woman's decline is usually very rapid after the 
birth of the child. 

Malaria is very apt to cause abortion, either by reason of 
its high temperature or because of the large doses of quinine 
given for its control. It must be said, however, that physicians 
practising in malarial districts give quinine to pregnant women 
without any regard to its oxytocic properties, and claim that 
under these conditions — that is, when given to a pregnant woman 
who is actually suffering from malaria — it has no tendency to 
cause miscarriage. In any event, the physician is between two 
horns of a dilemma when he encounters severe malaria compli- 
cating pregnane}', for if quinine is not given, through fear of 
causing abortion, the high temperature of the disease will most 
probably do so. 

Syphilis is the most common cause of all abortions, and a 
syphilitic patient should be under active treatment from the very 
beginning of gestation if she wishes to be at all certain of going 
to term and giving birth to a living child. The nurse should 
remember that syphilis is often encountered where it is least 
■expected, and that her professional acquaintance with the dis- 
ease will by no means be limited to her hospital training. 

All of the eruptive fevers, syphilis, tuberculosis, malaria, and 
lead and sewer-gas poisoning may directly affect the foetus in 
utero, and although the last two conditions do not cause any 
very serious disturbances if the child lives, they are very apt to 
cause abortion at an early period. 



VIII 

The Signs and Symptoms of Pregnancy 

As stated in the introductory chapter, it is highly desirable 
for the pregnant woman to be under medical care from as early 
a date as possible, and as women who suspect that they are 
pregnant are very apt to discuss the matter with a nurse before 
consulting a physician, the first duty of the nurse under such 
circumstances is to advise the patient of the importance of 
seeking medical counsel at once. 

More than half the women who present themselves at the 
physician's office late in pregnancy have nurses engaged for 
their confinements, and yet it seldom happens that these patients 
visit the physician by the direction of their nurses. In short, 
it would seem that nurses and physicians do not work together 
in such matters to the extent that they should, and it rests with 
the nurses to bring about a more harmonious state of affairs. 

Naturally, before advising a patient to consult a physician 
in regard to a suspected pregnancy, the nurse will wish to be 
reasonably sure in her own mind that conception has actually 
occurred. 

There are many signs and symptoms which point to the 
existence of pregnancy, some of which can readily be recog- 
nized by the nurse, while others can only be made out accurately 
by one who has had a thorough medical training. 

Of these signs, but three are absolutely indicative of preg- 
nancy, and of these, two may be absent if the foetus has died 
in the womb. Moreover, these " positive" signs are not present 
until about the middle of gestation, when the physician can 
usually make a diagnosis without them by the " circumstantial 
evidence" of a combination of earlier and less significant symp- 
toms. 

While, in the great majority of cases, the early diagnosis of 
pregnancy is extremely easy to one familiar with such condi- 



MORNING SICKNESS. 99 

ticns, it occasionally presents many difficulties, even to the 
skilled observer, and in rare instances no positive statement 
can be made until one or another of the three positive signs has 
appeared. 

The signs of pregnancy are divided by most writers into 
three groups, and in the following table those which are appre- 
ciable to the educated nurse are printed in heavy-faced type. 

A. PRESUMPTIVE SIGNS. 

i. Menstrual Suppression. 

2. Vomiting. (" Morning Sickness.") 

3. Irritability of the Bladder. 

4. Mental and Emotional Phenomena. ("Morbid 

Longings, etc.") 

B. PROBABLE SIGNS. 

i. Mammary Changes. (Enlargement of the 
Breasts, Shooting Pains, Pigmentation, etc.) 

2. Bimanual Signs. (Size of Uterus, Hegar's Sign, etc.) 

3. Abdominal Changes. (Size, Shape, Pigmenta- 

tion, etc.) 

4. Changes in Cervix. (Size, Shape, Consistency, etc.) 

5. Violet Color of the Vaginal Mucous Membrane. 

6. Uterine Murmur. 

7. Intermittent Uterine Contractions. 

C. POSITIVE SIGNS. 

i. Passive Fetal Movements. (" Ballottement.") 

2. Active Fetal Movements. ("Quickening.") 

3. Fetal Heart Sounds. 

Cessation of menstruation and morning vomiting are 
placed first in the list of Presumptive Signs because the former 
is the symptom usually first noticed by the patient and the latter 
is the one that is most likely to bring her to the physician. 

The writer has found, however, that irritability of the blad- 
der, characterized by very frequent and often more or less pain- 
ful voiding of the urine, is apt to be the first symptom of 

L0I 



ioo A NURSE'S HANDBOOK OF OBSTETRICS. 

pregnancy. This may occur very shortly after conception and 
before the next menstrual period is due, and as it is often 
ascribed by the patient to " catching cold," or to some other 
trivial cause, it is not, as a rule, mentioned, except in response to 
the questioning of the physician. This irritability is due to the 
pressure, on the bladder, of the recently impregnated uterus, 
which has a tendency to tip forward and settle down deeply in 
the pelvis, and, when accompanied or followed by stoppage of 
the menstrual flow it is, in a married woman, very suggestive 
of pregnancy. 

If this combination of symptoms is followed by vomiting on 
arising in the morning, or even by nausea at this time, the diag- 
nosis becomes more probable than ever. 

The usual character of this form of vomiting is that of a 
sudden, paroxysmal emptying of the stomach, occurring the 
moment the patient gets out of bed. Under normal conditions, 
it may continue until about noon, the stomach promptly reject- 
ing any food or drink that ma}- be swallowed. After twelve 
or one o'clock the irritability of the stomach usually ceases, 
and the patient has no further trouble or discomfort until the 
next day, when the whole affair is repeated. This symptom 
begins, as a rule, about the end of the second month, but it 
may be noticed at any time after conception has occurred, even 
as early as the third or fourth day. It generally stops by the 
end of the fourth or fifth month, and vomiting occurring late 
in pregnancy is always to be regarded with suspicion, as indica- 
tive of some severe systemic disturbance of toxaemic origin. 

Mental and emotional phenomena are, fortunately, not 
very common, but they may be noticed in some cases. For 
example, a woman of the most amiable disposition may, under 
the influence of pregnancy, become exceedingly disagreeable and 
fretful, while, on the other hand, one of great asperity may, 
rarely, go to the opposite extreme and take on the qualities of a 
veritable saint. In the same way, articles of food and forms of 
amusement, ordinarily unthought of, may suddenly be demanded, 
and in rare instances the most unusual and even disgusting 
impulses may be fostered. The writer has had recently under 



CHANGES IN THE BREAST. 



101 



his care a woman who, when pregnant, developed an irresistible 
appetite for raw potatoes. 

The changes in the breast include enlargement of the 
entire gland on both sides ; a sense of fulness, and shooting or 
tingling pains in these organs ; and darkening of the tissues 
surrounding the nipples (Fig. 36). Temporary slight enlarge- 




Fig. 36.— Marked pigmentation of breast. Tubercles of Montgomery and a drop of milk 
on the nipple plainly shown. 



ment of the breasts and sensations of weight and fulness are, of 
themselves, of no significance, for, in many women they may be 
noticed at the ordinary menstrual periods, but the darkening of 
the areola around the nipples and the presence of a silvery white 
fluid (colostrum), which can be squeezed out of the breast, 
constitute, in a woman who has never borne children, very 
significant signs of pregnancy. If, however, the woman has 
had a child, the areolar pigmentation from the previous preg- 
nancy will remain, and it is not unusual for colostrum to be 
present for months or even years after it ' has once appeared. 
Thus, while it is apparent that these breast symptoms are not 
of much account in the case of a woman who has borne chil- 



102 A NURSE'S HANDBOOK OF OBSTETRICS. 

dren, they are of great significance if the patient has never been 
pregnant before. 

The abdominal changes are supposed to begin with a flat- 
tening of the abdominal wall in the early weeks of gestation, 
due to the tipping forward and sinking of the uterus, to which 
reference has already been made as causing irritability of the 
bladder. This supposititious flattening has given rise to the old 
French saying, — 

" Ventre plat, 
Enfant il y a ;" 

which doggerel, being translated freely and with equal poetic 
feeling, would read, — 

" In a belly that is flat 
There's a child, be sure of that;" 

but, as King has said, " One can't be sure of that," by any 
means. In the first place, the uterus at this time is so small 
that no change in its position would have any tendency to 
appreciably flatten or otherwise affect the contour of the ab- 
dominal wall, and even if such a change did occur it would be 
so slight that it is highly improbable that it would ever be 
noticed by the patient or brought to the attention of the physi- 
cian or nurse. 

The pigmentation of the abdomen (see Fig. 32), extend- 
ing up the median line and surrounding the umbilicus is, in a 
woman who has never borne children, almost diagnostic of 
pregnancy, but, like the pigmentation of the breast, it varies 
exceedingly in different subjects, being often entirely absent in 
decided blondes and exceptionally well marked in pronounced 
brunettes. In women who have borne children previously this 
pigmentation remains from the former pregnancies, and cannot 
be depended upon as a diagnostic sign. 

The size of the abdomen in pregnancy corresponds with 
the increase in the size of the uterus, which, at the end of the 
third month is at the level of the symphysis pubis, at the end of 
the sixth month at the level of the umbilicus, and towards the 
end of the ninth month at the ensiform cartilage (Fig. 37). 



PASSIVE FETAL MOVEMENTS. 



103 



Mere abdominal enlargement may be due to a number of causes, 
such as an accumulation of fat in the abdominal wall, dropsy, 
uterine or ovarian tumors, and the like. If, however, the uterus 






Fig. 37.— Size of the uterus at each month of pregnancy. The fundus reaches the 
symphysis at the third month, the umbilicus at the sixth month, and the ensiform cartilage 
at the middle of the eighth month, after which it sinks a little before labor begins. 

can be distinctly felt to have enlarged in the proportions stated 
above, pregnancy may properly be suspected. The nurse cannot 
be expected to make out this uterine enlargement until the fundus 
is well above the symphysis, so this sign is of no value to her as 
a means of early diagnosis. 

The nurse will hardly be called upon to inspect the vaginal 
mucous membrane for evidences of pregnancy, but it may be 
said that, owing to pressure and consequent congestion within 
the pelvis, this mucosa becomes thickened and of a dark violet 
or purple color instead of its customary pinkish tint in the non- 
pregnant state. This sign is of no special value in women who 
have borne children, and as it may be due to any form of con- 
gestion or to the presence of new growths or varicosities within 
the pelvis, it is very unsatisfactory at best. 

Passive fetal movements (" ballottement' , ) can only be 
made out by the physician skilled in obstetric examinations, but 
the active movements of the foetus within the womb are readily 



io4 



A NURSE'S HANDBOOK OF OBSTETRICS. 



recognized after the fifth month by placing the hand firmly 
against the abdominal wall over the uterus and holding it there 
until the foetus is felt to kick vigorously, as it does every few 
minutes. This sign is unmistakable to the examiner, although 
the patient may sometimes imagine the movements of gases in 
the intestines to be the motions of a foetus within the uterus. 
If the child is dead these movements will not be felt, but there 
will usually be a history of the previous occurrence of such fetal 
activity. 

The sounds of the fetal heart are often heard with great 
difficulty by the physician, and it is not to be expected that a 
nurse will always be able to make them out. Occasionally, 
however, in the latter months of pregnancy and with all con- 
ditions favorable, the nurse will be able to hear the fetal heart- 
beat, like the ticking of a watch under a pillow, by placing the 
ear firmly against the abdominal wall. 

The fetal heart should make from one hundred and thirty 
to one hundred and fifty beats to the minute, and is absolutely 
distinct from the maternal pulse. Like active fetal movements, 
this sign will not be discovered if the child is dead. 

Having decided, from one or more of the above signs, that 
the woman is probably pregnant, or if there is any doubt as 
to her condition, she should be directed to consult, at once, the 
physician who is to attend her during her confinement. 

The probable date of the labor may be computed by 
taking the first day of the last menstruation, counting back three 
months, and adding seven days. This will give a date which 
is to be regarded as the middle of a period of two weeks during 
which the labor may be expected to occur. Thus, if the woman's 
last menstruation began on June 14, count back three months 
to March 14 and add seven days, making March 21. She may 
then be told that her labor will probably take place between 
March 14 and March 28. Remember that this is merely an 
approximate date, for the exact time of impregnation can seldom 
be determined, and it is not at all certain that the woman will 
go her complete term of two hundred and eighty days after 
impregnation, even if that date were positively known. 



IX 

The Management of Pregnancy 

When the pregnant woman consults the physician in refer- 
ence to her condition, he will first determine the duration of 
the gestation and the probable date of the expected labor, 
and then give the patient some general hygienic rules for her 
guidance during her pregnancy. 

It is not only proper, but important, for the nurse to have 
a clear understanding of the nature of these directions. 

Corsets and any other garments that constrict or compress 
the chest, waist, or abdomen must be laid aside from the first 
and the skirts supported from the shoulders by means of some 
form of " corset-waist," of which the " Ferris waist" is a well- 
known type. 

The reasons for this rule are many and important. In the 
first place, anything that compresses the chest retards greatly 
the development of the breasts, which should be marked during 
pregnancy, and by so doing tends to flattening or even depression 
of the nipples. Both these conditions will interfere with the 
function of lactation, even if they do not render it entirely 
impossible, and as the proper performance of nursing has a 
direct and powerful effect on the involution of the uterus and 
its return to its normal condition after labor, any such inter- 
ference exerts a most unfavorable influence on the convalescence 
of the mother as well as upon the health of the infant thus 
deprived of its logical form of nourishment. 

Moreover, pressure on the chest wall, especially as it is 
increased from day to day by the gradual enlargement of the 
breasts without any compensating loosening of the corsets, pre- 
vents necessary expansion of the lungs and hinders the working 
of the heart, already hypertrophied as a normal result of preg- 
nancy. The harmful consequences of such conditions can 
readily be seen, for it is not difficult to understand that a woman 

105 



106 A NURSE'S HANDBOOK OF OBSTETRICS. 

who has to supply oxygen for herself and another being, and 
who must eliminate, with her own blood, the waste products 
of an unborn infant as well as those of her own body, must 
necessarily have her respiratory and circulatory organs unham- 
pered if she is to perform these tasks in a thoroughly normal 
way. 

The injurious results of pressure about the waist and abdo- 
men are much the same. Respiration is affected by interference 
with the play of the abdominal muscles and the diaphragm; 
circulation is impeded by pressure on the large abdominal blood- 
vessels ; the normal action of the kidneys, liver, and digestive 
organs is seriously hampered; and, lastly, the full development 
of the infant is markedly interfered with. 

The use of corsets and the practice of " lacing" during 
pregnancy are usually due to a desire on the part of the mother 
to conceal her condition as long as possible, coupled with igno- 
rance of the disastrous results that may, and often do, follow 
the employment of such means of concealment. 

Most women will abandon these devices at once when their 
dangers have been carefully explained, and the few whose short- 
sightedness and vanity are so great that they are willing to take 
chances with their health and ignore entirely the future welfare 
of their unborn children for the sake of a few more weeks of 
participation in social pleasures, usually suffer, in after years, 
all the penalties to which their selfish unwomanliness entitles 
them. 

Undergarments should be made of wool, of a weight suited 
to the season of the year, and should extend down to the ankles 
and cover the arms to the wrists. They may be in tw T o parts, 
vest and under-drawers, or the so-called " combination suit," 
made in one piece, may be worn. The essential point is that 
the entire body be covered with woollen material, whether in 
winter or summer. 

Wool is insisted upon, to the exclusion of cotton or linen, 
because it absorbs perspiration as rapidly as it is excreted, and 
so keeps the skin dry at all times. When the integument is 
damp with perspiration, as it is in hot weather or after exertion, 



WEARING APPAREL. 



107 



if cotton or linen underwear is worn, any sudden chilling of 
the' surface will close the capillaries and drive a considerable 
amount of blood to the interior of the body, causing conges- 
tion of the internal organs. At the same time, this chilling of 
the surface and contraction of the capillaries prevent further 
perspiration, and so throw an additional strain on the kidneys, 
now congested through increased blood-supply and overworked 
by the addition of fetal to the maternal elimination. 

Outer garments are to fit loosely, and must be enlarged 
as freely and as frequently as occasion requires. Decollete 
gowns are strictly forbidden at any time during pregnancy. 

Garters that encircle the leg tend to the development of 
varicose veins in the lower extremities, and are to be discarded 
in favor of some form of stocking supporters attached to the 
corset-waist or extending over the shoulders. It will be re- 
membered that arteries have muscular tissue in their walls, 
while veins have none, and that arteries stand open when empty, 
while veins collapse". Hence any constriction of an extremity 
affects the veins far more than the arteries, and blood, which 
meets with no obstruction whatever in its flow down the ex- 
tremity through an artery, will, on its return through the vein, 
find at the point of constriction sufficient closure of the vessel 
to dam it back and so stretch the vein wall that a varicosity 
is formed. As there is already a marked tendency in this direc- 
tion, by reason of the enlarged and constantly enlarging uterus 
impeding return circulation from the lower extremities by com- 
pression of the great abdominal vessels, anything like corsets 
or garters tends to aggravate the condition. In fact, garters 
that encircle the leg should never be worn under any cir- 
cumstances, even by unmarried women, for the tendency to 
varicosities is always present, and when once they are formed 
they not only never disappear but grow worse from year to 
year. 

Exercise in the open air should be taken daily throughout 
the entire course of pregnancy, and, of all forms of exercise, 
walking is, without question, the best. Smooth roads are to 
be selected for the daily jaunts, and they must be so regulated 



108 A NURSE'S HANDBOOK OF OBSTETRICS. 

as to distance that the woman will arrive home exhilarated, 
but just within the point of fatigue. 

A woman of ordinarily good physique, beginning her walks 
early in pregnancy, should start with about one mile and in- 
crease the distance half a mile a day until six miles are covered. 
When this distance is reached it is to be regarded as the regular 
daily task if it can be accomplished comfortably, but if it prove 
to be exhausting it must be cut down to a more suitable length. 

While six miles a dav is not too much for a strong: healthy 
woman accustomed to out-door life, and may safely be taken 
as a standard for comparison, it must never be forgotten that 
many patients of frailer constitution can be allowed only two 
or three miles a day. and no woman should ever be urged to 
undertake more than her strength will permit. 

The final test lies in the condition in which the patient re- 
turns home. If she is tired and worn out, the distance has been 
too great, while if she is invigorated and refreshed at the end 
of her walk, it has been beneficial. 

Moderately stormy days need not interfere with the usual 
outing if the woman is properly dressed for the weather, with 
rain coat, high storm boots, and rubbers or overshoes. The 
dangers of chilling the body, and consequent congestion of the 
internal organs, must always be kept in mind, and if, by any 
accident, a pregnant woman is inadvertently exposed to in- 
clement weather and returns home cold and exhausted, steps 
must be taken at once to stimulate surface circulation and 
restore warmth to the body. 

A hot drink of tea, or whiskey and sweetened water, should 
be given, and then, after all clothing has been removed, the 
patient is to be rubbed vigorously, wrapped in warm blankets, 
and surrounded with hot water bottles, or, if they are not 
available, with hot flat-irons or hot stove-lids. 

As soon as she is perfectly comfortable and entirely free 
from all chilly sensations, the blankets are removed and she is 
again rubbed briskly with warm diluted alcohol and dressed in 
warm clothing, unless she prefers to remain in bed between 
sheets. She is to lie in the blankets only long enough to get 



IN-DOOR EXERCISE. 109 

thoroughly warm and not until she begins to perspire. The 
hot whiskey is not to be repeated, but small quantities of hot 
tea may be given from time to time. 

Walking is preferred during pregnancy to every other form 
of exercise, because it stimulates the muscular activity of the 
entire body, and in the later months it distinctly favors the de- 
scent of the fetal head into the pelvis, insures complete flexion, 
and shortens materially the first stage of labor. Moreover, it 
is available to all women, no matter what their circumstances 
in life may be. It should be kept up to the very end of preg- 
nancy,, and in the last months, when the patient's condition is 
noticeable, the walks may be taken after dark to avoid the 
embarrassing glances of passers-by. 

Aside from walking, there are very few forms of out-door 
exercise that meet the requirements of the pregnant woman. 
Horseback riding is too violent and driving not sufficiently in- 
vigorating ; tennis is too uneven and tiresome, and croquet 
too tame and uninteresting ; while golf in moderation and 
bicycling over smooth roads are debatable questions, and may 
possibly, be permitted. Walking is the best of all, and if any 
of the other permissible forms are allowed it should be only at 
rare intervals and on special occasions. This is especially true 
of all forms of out-door games, for the patient's spirit of emu- 
lation and her desire to make a good showing, if not to be the 
winner, may result in overtaxing her strength to a serious 
degree. 

Of ix-door exercise there is only one form worthy of con- 
sideration. This consists in stimulating the abdominal muscles 
by lying on the back on the bed or floor and, with the arms 
folded over the chest or the hands clasped back of the head, 
rising to a sitting posture without drawing up the legs or 
raising the heels. This is to be repeated several times until 
a slight sense of fatigue is experienced, and should be begun 
early in pregnancy and practised twice daily, in the morning 
before arising and at night just after retiring. 

If this form of exercising the abdominal muscles is found 
to be too difficult, as is often the case, the patient may, instead, 



HO A NURSE'S HANDBOOK OF OBSTETRICS. 

lie on her back and raise the feet slowly in the air, first one foot 
at a time and then both feet together. This should be done 
several times until a slight sense of fatigue is experienced. 

Dancing, ping-pong, and the like are strictly forbidden, and 
the sewing-machine, a most potent factor in the causation of 
miscarriages, must never be used in pregnancy. The lifting 
or carrying of heavy weights, all unnecessary stair-climb- 
ing, and every form of violent exertion must studiously be 
avoided. 

Bathing at frequent, stated intervals is of the utmost im- 
portance, and baths should be taken daily during the hot sum- 
mer months, and not less than three times a week in cooler 
weather. Warm water and an abundance of soap are to be 
used, for it is essential to keep the skin in good condition and 
the pores free, lest perspiration be interfered with and too great 
a strain be thrown upon the kidneys. 

The relation of perspiration to the action of the kidneys 
is little understood by the laity, and most persons are unaware 
that the skin of an adult excretes, in twenty-four hours, from 
one and one-half to two pints of fluid, or nearly as much as 
is eliminated in the form of urine, and that if perspiration were 
to cease entirely, the kidneys would be unable to perform the 
double task which would be required of them, and death would 
inevitably result within a few hours. 

This fact was most tragically proved in Paris many years 
ago when a little boy, chosen, because of his unusually beautiful 
form, to represent an allegorical figure at a national festival, 
was covered completely with gold leaf to simulate a golden 
statue, and died in a few hours of ursemic convulsions merely 
because perspiration was completely stopped and the kidneys 
were unable to bear the extra burden. 

Baths are best taken at night, just before retiring, to avoid 
the danger of " catching cold," but a morning bath may be 
allowed, even with tepid or cool water, if the patient has always 
been accustomed to one. The shower-bath or spray cannot with 
safety be permitted at any time during pregnancy. Salt water 
" still" bathing is usually beneficial when practised under proper 



THE TEETH. Ill 

conditions, but surf bathing is distinctly contraindicated through- 
out the entire period of gestation. 

Sleep, in greater amount than usual, is required by the preg- 
nant woman, and, in addition to the regular sleep at night, a 
nap of one or two hours in the afternoon is highly desirable. 
If the patient is unable to sleep in the daytime, the afternoon 
nap should not be entirely given up, but she should lie down 
on the bed or couch and rest quietly for an hour or two every 
day. 

The bedroom should be of good size, in a quiet part of the 
house and thoroughly well ventilated. Even on the coldest win- 
ter nights a window can be opened a few inches at the top and 
bottom to insure a free circulation of fresh air. If the bed is, 
necessarily, so situated that it is in the direct line of draft, a 
screen may be placed at its side, or, if such a piece of furniture 
is not available, one may be improvised with a kitchen clothes- 
horse, covered with a sheet. 

The teeth of a pregnant woman are apt to undergo cer- 
tain destructive changes, which have given rise to the old say- 
ing, " For every child, a tooth." This disorder is supposed to be 
due to increased acidity of the saliva, which is itself increased 
in amount, and it may result in caries of a rapidly progressing 
type. In addition, the gums may grow soft and spongy, and 
even bleed or become ulcerated. In rare instances there is a 
persistent toothache, not due to any lesion of the tooth or gums, 
but of reflex origin. As a precautionary measure, the woman 
should have her teeth examined and put in order by a competent 
dentist early in pregnancy, for painful or protracted dental op- 
erations performed during the period of gestation have been 
known to bring on miscarriage. 

After the teeth have been thoroughly cleaned and any exist- 
ing cavities temporarily filled, further trouble can usually be 
averted by the frequent and systematic use of an alkaline mouth- 
wash. Phillips' " Milk of Magnesia " meets this indication per- 
fectly, and, after brushing the teeth, the mouth should be rinsed 
with a properly prepared solution before and after each meal, as 
well as after arising and before retiring. 



112 A NURSE'S HANDBOOK OF OBSTETRICS. 

If the teeth have been properly put in order by a dentist in 
the early weeks of pregnancy, and if this after-care has been 
faithfully followed out by the patient, any pain or soreness of 
the teeth, mouth, or gums which does not subside promptly 
should be reported at once to the physician. 

The diet of the pregnant woman is to be carefully regulated, 
and only such articles of food are to be taken as will not over- 
tax the already hard-worked kidneys. The appetite at this time 
is often enormously increased, especially in the case of a strong, 
healthy woman in whom there are no abnormalities and whose 
pregnancy is progressing favorably. 

To gratify to its full extent this abnormal desire for food, 
which -is most marked after the fourth month, when the morning 
nausea or vomiting has disappeared, is extremely dangerous to 
both the mother and child. Professor Hirst speaks of a case, 
seen by him in consultation, in which a primigravida who had 
not only been allowed full sway in the matter of diet, but who 
had been directed by her physician to drink two quarts of milk 
daily, between meals, was delivered, with the utmost difficulty, 
of a child weighing eleven and three-fourths pounds. Later, 
under a properly regulated diet, she was delivered, with com- 
parative ease, of a perfectly healthy, well-developed child which 
weighed but seven and one-half pounds. 

Thus, it is evident that an unrestricted diet will, if it does 
nothing more, tend to overgrowth of the foetus and, conse- 
quently, to serious complications at the time of labor. 

While this state of affairs is sufficiently bad, such a child 
could, if necessary, be delivered by Cesarean section, which, 
amid favorable surroundings, and performed by a skilful opera- 
tor on a healthy woman, would, under modern surgical methods, 
doubtless result successfully. 

There is, however, another and even more important reason 
why the character and amount of food ingested during preg- 
nancy must be carefully regulated. The strain to which the 
kidneys are subjected during pregnancy has already been men- 
tioned several times, and an excess of food, especially if it is of 
an unsuitable kind, adds to this strain materially. If, then, this 



DIET IN PREGNANCY. 1 13 

inordinate indulgence at the table and between meals is allowed 
to continue, the time may, and often does, come when some 
extra excess will serve to " break the camel's back" and throw 
the patient into a condition of eclampsia. Hirst mentions an 
instance of this kind, when a hearty Thanksgiving dinner was 
enough to bring on uraemic convulsions in an apparently healthy 
pregnant woman, with the result that the child was lost and the 
life of the mother saved only after most vigorous and prolonged 
treatment. 

The exact cause of uraemic convulsions (eclampsia) during 
pregnancy is still a problematic question, and while many theo- 
ries have been advanced in explanation of these phenomena, 
none has been accepted definitely by the entire medical pro- 
fession. 

One general statement may be made, however, and it is a 
sufficiently safe working theory for the nurse to keep in mind 
and regard at all times as a correct explanation of the cause of 
these convulsions. This is, that eclamptic convulsions are due 
to a storing up in the system of matter which should be elimi- 
nated either by the kidneys, the liver, or the digestive tract. 
It will be remembered that the mother has to eliminate not only 
her own waste products, but those of her infant as well, and 
that, at the same time, her organs of elimination are handicapped 
by pressure from the growing uterus and by the other dis- 
turbances in the general working of the bodily functions that 
always accompany pregnancy. This pressure and the accom- 
panying disorders of nutrition increase as pregnancy advances, 
and the danger of digestive disturbances grows greater from 
week to week. Even in the early months, when the pressure is 
slight and the functions of the emunctories have not been seri- 
ously affected, the diet must be carefully regulated to avoid a 
break-down when the strain is greatest. 

No hard and fast diet-sheet can be laid down for the preg- 
nant woman, and under ordinary circumstances, beyond limit- 
ing the use of red meat to once a day, she may be allowed to 
choose for herself so long as she selects only nutritious food 
of an easily digestible character. Red meat is limited, even in 



H4 



A NURSE'S HANDBOOK OF OBSTETRICS. 



normal cases, because, being rich in nitrogenous matter, it is 
apt to cause sluggishness of the liver, intestinal fermentation, 
and indigestion, thus overtaxing all the organs of elimination 
and so tending to an accumulation of urea in the system. 

This retention of urea in the blood gives rise to the condition 
known as urccmia, and, if not promptly recognized and treated, 
is productive of convulsions and, possibly, death. In untreated 
cases nature usually makes an effort to get rid of the products 
of fetal elimination, and so save the mother, either by the death 
or the expulsion of the child, but, as will readily be understood, it 
is extremely dangerous, not to say unscientific, to depend upon 
any such uncertain means of relief. 

The occasional craving of pregnant women for unusual arti- 
cles of food must be kept in mind, and any desires of this kind 
may be granted with safety when the articles demanded agree 
perfectly with the patient and are not of too exceptional a nature. 
Any marked perversion of appetite should, of course, be reported 
promptly to the physician. 

While many patients will conscientiously follow directions 
expressed in a general way only, certain women will pay no 
attention to anything but the most explicit rules, and with such 
unruly cases the diet-sheet given below may be used to advan- 
tage. This list is, of course, only a general outline of the proper 
diet during gestation, for, as already stated, no absolute laws 
can be made to fit every case, and the likes and dislikes of the 
patient are never to be disregarded entirely. Food must be of 
such a character that the patient enjoys her meals thoroughly 
and gains regularly in weight and strength from day to day. 

PROPER DIET DURING PREGNANCY. 

Soups. — Any kind. 

Fish. — Boiled or broiled fresh fish of any kind. Raw oys- 
ters and raw clams. 

Meat. — Chicken, game, ham or bacon (broiled), tender lean 
mutton and lamb. All meats, more or less sparingly; and red 
meat is allowed only in perfectly normal cases, and then but 
once daily. 



DIET DURING PREGNANCY. 115 

Farinaceous. — Hominy, oatmeal, wheaten grits, mush, rice, 
sago, tapioca, arrow-root, stale bread, Graham bread, rye bread, 
brown bread, corn bread, toast, milk toast, biscuits, macaroni. 

Vegetables. — Potatoes, cabbage, onions, spinach, cauli- 
flower, Brussels sprouts, asparagus, green corn, green peas, 
string beans, mushrooms, water-cress, lettuce or other salads 
with oil. 

Desserts. — Plain puddings of rice, arrow-root, sago, or 
tapioca ; custards, stewed fruits, ripe raw fruits, and ice-cream. 

Drinks. — Plenty of pure water (hot, cold, or aerated), at 
least two quarts daily, milk, butter-milk, peptonized milk, 
kumyss, or zoolak. Very little tea, practically no coffee, and 
absolutely no alcoholic liquors unless specially ordered by the 
physician. 

Such a list is susceptible to many additions and elaborations, 
but, in the absence of specific instructions from the physician, 
it will answer perfectly well to give to such patients as insist 
upon positive dietetic directions. 

The bowels of the pregnant woman are to be watched care- 
fully, and at least one satisfactory evacuation must be secured 
daily. 

Constipation will probably be encountered, as nearly all 
women are more or less constipated, and this condition is usu- 
ally greatly aggravated during pregnancy. For its relief the 
fluid extract of cascara sagrada may be ordered at bedtime, in 
doses of from one-half to one teaspoonful, or the official pill 
of aloin, strychnine, and belladonna may be given two or three 
times daily. In addition it is well to administer a gentle saline 
laxative, such as the effervescent solution of citrate of magnesia, 
a Seidlitz powder, or Saratoga " Congress " water every third or 
fourth morning, before breakfast. 

The dangers of constipation in causing an accumulation of 
excrementitious matter in the system have already been pointed 
out, as tending to the development of uraemia and eclamptic 
convulsions. Moreover, the mere mechanical effect of an over- 
loaded bowel is to increase the pressure on the vital organs in 
a pelvis already filled to its utmost capacity. 



li6 A NURSE'S HANDBOOK OF OBSTETRICS. 

Diarrhoea, on the other hand, is also a condition that cannot 
safely be neglected, for even if it is of simple origin and not 
due to any serious intestinal disturbance, it may, if allowed to 
continue, be enough to undermine the patient's strength to a 
dangerous degree. Prolonged or severe diarrhoea is often a 
direct cause of miscarriage as well, and any such condition of 
the intestinal tract which is not controlled promptly by simple 
home remedies, such as a draught of blackberry brandy, a dose 
of chalk mixture, or one of cholera mixture, should be reported 
to the physician without delay. 

The nervous condition of the pregnant woman has already 
been referred to, and the nurse must do all in her power to 
make this trying period as pleasant and enjoyable as she can, 
both by her own efforts towards entertaining the patient and 
diverting her mind from subjects that annoy or irritate her, 
and by her advice and example to the members of the family 
as to the cause of any disagreeable traits that the woman may 
develop. It is, of course, not expected that the patient will fail 
to do her own share towards the preservation of harmony, and 
it is never a wise plan to bow submissively to her actions at 
all times, nor to allow her to think that merely because she is 
pregnant she is at liberty to be as exacting and unreasonable 
as she pleases. What is needed is the exhibition of a tactful 
restraint over her more exaggerated moods and a complacent 
disregard of trivial matters. 

During the last two months of pregnancy special atten- 
tion must be paid to the condition of the kidneys and the prepa- 
ration of the breasts for nursing. 

A specimen of urine is to be sent to the physician's office 
once a week without fail, and oftener if he requires it. This 
should be from. the mixed urine of twenty-four hours, and the 
bottle must be securely corked and clearly labelled with the total 
quantity of urine voided in the time mentioned, the patient's 
name, her address, and the date. This label should be pasted 
to the bottle and not written on the outside wrapper, which is 
often destroyed or mislaid as soon as it is removed. At least 
four ounces of urine should be sent, and the bottle should reach 



CARE OF THE BREASTS. 1 17 

the physician in the early part of the forenoon, so that he can 
examine the specimen at his convenience. 

The breasts must be prepared for nursing by careful atten- 
tion to the condition and development of the nipples, for if the 
infant is unable to nurse, both it and its mother will suffer more 
or less. 

The effect of stimulation of the breasts, by suckling, on the 
involution of the uterus has already been mentioned, and it will 
readily be understood that the infant will thrive better on breast 
milk than on any other kind of food. 

The breasts should be bathed night and morning with soap 
and warm water, to keep the skin in the best possible condition, 
and after the bathing they are to be sponged briskly with water 
as cold as the patient can bear, to stimulate the activity of the 
glandular tissue. 

It has been said that gentle massage of the breasts with lano- 
lin once daily during the latter part of pregnancy will effectu- 
ally prevent the formation of the silvery lines or striae due to 
the distention of the skin (see page 56) ; and this, if it is true, 
will be greatly appreciated by those patients whose social duties 
require them to wear decollete gowns. At any rate, it can do 
no harm and is well worth trying. 

If the nipples are small, flattened, or depressed, they must 
be drawn out with the forefinger and thumb and held for five 
minutes night and morning throughout the entire two months 
preceding the labor. This will often develop them to a sur- 
prising degree, and nipples that at first seem absolutely unfitted 
for nursing can frequently be made sufficiently prominent by 
this treatment to meet the needs of the child perfectly. The 
patient can, of course, do this herself after the nurse has in- 
structed her in the proper method, but, as has been stated in a 
previous chapter, she must be cautioned as to the possibility 
of irritating the uterine muscle to contraction by too vigorous 
manipulation of the nipples, and warned to stop this treatment 
at once should any uncomfortable symptoms develop in the 
uterus or lower abdomen. 

If there are erosions, fissures, or other diseased condition 



Il8 A NURSE'S HANDBOOK OF OBSTETRICS. 

of the nipples, the physician should be consulted and will pre- 
scribe appropriate treatment. 

All nipples, no matter how well developed and healthy they 
may be, are to be anointed every night with white vaseline or 
albolene, which is to be carefully removed in the morning with 
castile soap and warm water. This is to soften and remove 
the colostrum which the breasts secrete during the latter part 
of pregnancy, and which, if undisturbed, will form hard crusts 
on the nipples and excoriate the delicate tissues beneath. 

Nipples which are not treated in this way and upon which 
crusts of colostrum are allowed to remain are often extremely 
sensitive or even exquisitely painful when nursing is begun, 
and are especially liable to the formation of erosions or fissures 
which may prevent nursing entirely, either because of the suffer- 
ing caused by the suckling or by the development of inflamma- 
tion in the breast itself. 

AS A GENERAL RULE FOR THE GUIDANCE OF THE NURSE in 

the management of pregnancy it is safest and wisest to report 
to the physician any condition that causes the patient special 
discomfort or that seems to be at all unusual. 

As A GENERAL RULE FOR THE GUIDANCE OF THE NURSE ill 

the management of pregnancy it is safest and wisest to report 
to the physician any condition that causes the patient special 
discomfort or that seems to be at all unusual. 



The Nurse's Outfit 

The care of obstetric cases presents so many differences 
from ordinary surgical nursing that the nurse requires a few 
special articles for this work in addition to her usual outfit. 

In the first place she should provide herself with an abundant 
supply of dresses and aprons, for the nature of her duties are 




Fig. 38. — Operating gown and case. 



such that, even with the utmost care, she cannot always prevent 
frequent soiling of her aprons at least. In addition to her white 
aprons she should have one large rubber apron for use when 
she is bathing the baby. 

119 



120 A NURSE'S HANDBOOK OF OBSTETRICS. 

An operating-gown (Fig. 38), pinned in a towel or tied up 
in a muslin case, and sterilized, should be taken for use at the 
time of the delivery. Nurses often come to a case several days 
before the labor occurs, and, while wearing their uniforms, they 
are up- and down-stairs and in all parts of the house. Also, 
as will be seen in another chapter, the patient receives an enema 
at the beginning of labor, and frequent trips to the bath-room 
have to be made by the nurse on this account. Keeping these 
various matters in mind, it is evident that the nurse's uniform 
is anything but aseptic when labor is in progress, and the gown 
should be worn from the time the patient takes to her bed until 
after the placenta is delivered. 

The nurses's arms should be bare to the elbows throughout 
the entire labor, and afterwards several times each day while 
she is attending to the toilet of the patient or bathing the baby. 
Frequent rolling up of the sleeves for this purpose soon rumples 
them to such an extent that they present a very disordered 
appearance, highly at variance with the picture of immaculate 
neatness which is always expected of a nurse. This difficulty 
may be obviated entirely by the use of " elbow sleeves " or by 
having special dress-waists made with sleeves that can be unbut- 
toned or unhooked just above the elbow and removed whenever 
necessary (Fig. 39). A little ingenuity on the part of the dress- 
maker is all that is necessary in designing an attractive and per- 
fectly practical garment of this kind, and its convenience will be 
appreciated as soon as it is used. 

Two thermometers should be taken to each case,— one for 
the mother's temperature and the other, a rectal thermometer, 
for the infant. There should be temperature charts for both 
mother and child in addition to the usual blanks for bedside 
notes. Temperature should always be charted, for its entire 
course can then be understood at a glance, while if it is recorded 
in any other way its significance is not always readily grasped, 
and unless the notes are studied with great care a single, iso- 
lated rise of temperature may escape the notice of the physi- 
cian. 

The infant is to be weighed at birth, and afterwards once 





Fig. 39. — Proper costume for obstetrical nurse, showing detachable sleeves. 



THE NURSE'S OUTFIT. 



121 



daily, and as scales are seldom to be had when they are wanted 
for this purpose, it is a good plan for the nurse to add to her 
obstetrics outfit a small scales and hammock, such as is shown 




HAMMOCK and 

SCALED 

ROLLED 




Fig. 40. — Scales and hammock for weighing infant. 



in Fig. 40. The best scales are large ones with weights, or the old- 
fashioned " steelyards," for no spring balance is exactly accurate; 
but in the absence of the bulky apparatus, the little pocket affair 



122 A NURSE'S HANDBOOK OF OBSTETRICS. 

shown in the illustration, and to be had of any dealer in surgical 
supplies, answers very well. The infant's weight should be 
recorded daily on a chart, and blanks for this purpose, having 
space for the infant's temperature and weight, the mother's 
temperature and pulse, and all the other required data of a 
maternity case, have been designed by the author.* 

A glass feeding-tube is needed for administering fluids to 
the patient immediately after labor and before she is allowed 
to raise her head. 

Tape for tying the umbilical cord is not mentioned in the 
list of supplies to be provided by the mother, because the physi- 
cian usually includes it in his own outfit, but occasionally it is 
overlooked, and at times, as in cases of precipitate labor, the 
nurse will have to tie the cord before the arrival of the physician. 
For these reasons it is best for her to provide herself with 
suitable cord ligatures, and the best material for this purpose 
is ordinary linen bobbin tape, to be found at any dry-goods or 
notion shop. 

The hypodermic case should contain tablets of ergotin in 
addition to the usual assortment of drugs. 

To recapitulate, the obstetric nurse needs, in addition to the 
ordinary supplies that she would take to any case, — 

Extra aprons. 

Extra dresses, preferably with detachable sleeves. 

One rubber apron. 

One operating-gown, sterilized. 

Two thermometers ; one for mouth, the other for rectum. 

Temperature charts. 

Scales for weighing the infant. 

Weight charts. 

Glass feeding-tube. 

Linen bobbin tape, for tying the umbilical cord. 

Hypodermic tablets of ergotin. 



* These charts are made up in pads, of fifty each and sold by C. C. 
Hine's Sons Co., ioo William street, New York City, who will send 
samples and quote prices on request. 



XI 

The Patient's Outfit 

Beginning at a sufficiently early date in pregnancy to enable 
her to have all her preparations made at least one month before 
labor is expected to occur, the prospective mother should make 
ready the articles which will be required at the time of her con- 
finement. 

This outfit may be divided into two parts ; one consisting of 
the articles needed for the mother's use, and the other of the 
supplies which will be required by the infant. 

In many cases the physician will give the patient a list of the 
supplies he wishes her to get, but where the matter is left in the 
hands of the nurse the following outfit will usually prove satis- 
factory : 

A. FOR THE MOTHER. 

Six abdominal binders, one and three-quarters yards long 
by three-quarters yard wide ; made of the cheapest grade of 
unbleached muslin. This muslin comes in a width of three- 
quarters yard, and ten and one-half yards are required to make 
the necessary number of binders. They should be torn in the 
proper length and then washed and ironed, to make them soft 
and comfortable. The cheapest grade of muslin is recommended 
because the more expensive, and consequently heavier, quality 
does not take the pins as well and is stiff and uncomfortable 
when in use. 

Two obstetrical pads for the bed, each twenty-four inches 
square and made of cheese-cloth stuffed with cotton batting (not 
absorbent cotton) until it is three or four inches thick. They 
should be " tacked" or tufted to keep the cotton from slipping, 
and are for use under the patient's buttocks during the first 
few hours after labor when the flow is greatest. When prac- 

123 



124 A NURSE'S HANDBOOK OF OBSTETRICS. 

ticable, it is well to have them sterilized before use ; but this 
is not absolutely necessary if, as should always be the case, 
they are made with surgically clean hands from new material. 

Thirty sanitary or vulva pads. These are made of ab- 
sorbent cotton, ten by three inches, and two inches thick, and 
covered with bleached cheese-cloth or plain absorbent gauze, 
which is really the same thing with the sizing washed out. They 
must be made of absolutely new and fresh material, with sur- 
gically clean hands, and, if possible, they should be sterilized 
before use. As soon as they are made they are to be done up 
in packages of six, and each package wrapped separately in a 
clean towel or in clean white muslin and laid away in a con- 
venient place, free from dust, until they are wanted. They are 
used during the puerperium to place over the vulva to receive 
and absorb the lochial discharge, and are to be changed as often 
as they become soiled. Soiled pads must be removed at once 
from the room and burned. 

One dozen clean towels, preferably old soft ones without 
fringe. These are to be pinned up in another towel and laid 
away with the other things. They are for use only about the 
patient, and are not for the hands of the physician or nurse. If 
a sterilizer is available they should be sterilized, but this is not 
indispensable if they were thoroughly boiled at their last 
washing. 

New diapers may be used in place of the towels if desired, 
but old ones may never be employed for this purpose. 

Safety-pins. Two papers of large and one of small size, in 
addition to those required for preparing the bed. 

One new nail-brush for the nurse. The physician should 
bring his own. The best for this purpose are those with plain 
wooden backs, costing five or ten cents each. 

Absorbent cotton. Half-pound. Johnson & Johnson's is 
the best. This amount of cotton will not last throughout the 
entire puerperium, but it will be enough for the first few hours 
immediately following the labor, and more can be bought from 
time to time as it is needed. 

Tincture of green soap. Four ounces. 



THE MOTHER'S OUTFIT. 125 

Alcohol (ninety-five per cent.). One pint. For dressing 
the umbilical cord and for bathing purposes. 

Two pieces of rubber sheeting, each one and one-half 
yards square. Of this sheeting one piece may as well be of the 
so-called " enamel-cloth " (white) which is often used for cover- 
ing kitchen table and shelves and is much less expensive. This 
piece may be used for covering the cot or couch upon which the 
patient is delivered, and, afterward, cut into smaller pieces for 
the baby's bed or bassinette. The other piece, of the regular 
quality to be had of the druggist, is for use on the patient's bed 
during the puerperium and, later, by the baby, who will require 
it for the following three or four years. 

Two wash-basins, preferably of agate or enamel-ware. 
These will be needed for solutions at the time of the labor ; after- 
wards for bathing the patient's genitals during the puerperium ; 
and still later for use about the infant. 

One slop-jar or pail, made perfectly clean and used during 
labor for receiving soiled sponges, towels, and the like, as well 
as any solutions or discharges that can be directed into it. 

A good supply of clean towels (in addition to the dozen 
already mentioned),- and plenty of sheets, pillow-cases, and 
night-gowns for the patient's use. Nothing is more annoying 
to the physician than to call for a clean sheet or night-gown at 
such a time, and find that it is not to be had ; while clean towels, 
almost without number, are needed in the lying-in room. 

b. for the infant. 

Olive oil. Six ounces. For anointing the infant imme- 
diately after birth and before it is washed. A good grade of 
salad oil answers every purpose. 

This practice of anointing the infant with olive oil, instead of 
washing it immediately after birth, is of the utmost importance, 
for it must be remembered that the temperature of the interior 
of the uterus is not far from 100 F., while that of the average 
lying-in room is seldom above 8o° F. ; a drop of 20 degrees. A 
child that is bathed with soap and water as soon as it is born 
runs great risk of " catching cold." 



126 A NURSE'S HANDBOOK OF OBSTETRICS. 

Solution boric acid. Six ounces. For cleansing the in- 
fant's eyes and mouth immediately after the head is born. 

One tube plain white vaseline. 

One cake of white castile soap. 

Six flannel binders, six inches wide by twenty-two inches 
long. Forty-cent flannel, or better if desired. 

One soft flannel blanket, one yard square, to wrap the 
infant in immediately after birth. Any old soft piece of woollen 
goods, such as an old flannel petticoat, will answer, but it must 
be scrupulously clean. 

Four dozen diapers of linen or cotton diaper cloth. The 
cotton cloth is just as good as the linen and is less expensive. 
Not less than four dozen should be provided, and it is a great 
convenience to have at least one or two dozen more. Diapers 
should be cut so that their length is exactly double their width. 
They are folded once into a square and a second time into a 
triangle. During the first few weeks of the baby's life the diaper 
must be folded a third time into a smaller triangle or it will be 
too large. Diaper cloth comes in various widths, and it is well 
to get part of the smaller and part of the largest size. 

One infant's bath-tub. The baby will not be bathed in 
the tub until after the umbilicus is healed, but it may be required 
at the time of the confinement for resuscitating an asphyxiated 
infant by immersion in hot water. 

One bath thermometer. The temperature of the infant's 
bath should never be " guessed at" by the nurse. 

One box of talcum powder. 

Two powder-boxes and puffs of different appearance, one 
for the buttocks and body and the other for the neck and ears. 

One small nail-scissors. 

One soft infant's hair-brush. 

A supply of small squares of absorbent gauze or clean old 
linen, for washing the infant's mouth, eyes, and ears, and to be 
destroyed after use. 

Two soft sponges of different size, one for the buttocks and 
one for the body. 

Six soft wash-cloths for the face and neck. 



THE INFANT'S OUTFIT. 127 

Two large soft bath-towels to wrap the child in after its 
bath. 

It will be seen that many of the above-named articles can be 
improvised from material already on hand. 

Four undershirts of stockinet, or silk and wool. 

Four petticoats of flannel. 

Four night-gowns of stockinet or flannel, according to the 
season of the year. 

Ten slips, the more simply made the better. 

The garments should all be made to open in the back, so that 
they may be fitted together and into the slip or dress, and all the 
clothing put on at once. (See Chapter XXII.) This style of 
garments may be purchased ready-made under the name of the 
" Gertrude Garments for Infants." 

The above outfit of clothing is the smallest possible allow- 
ance with which the child can be kept clean and comfortable, and 
it would not be an extravagance to double the number of under- 
garments given. 

The various articles for the mother and infant are to be laid 
away in a convenient place where they will be readily accessible 
to either the physician or nurse, preferably in bureau drawers 
which have been emptied and cleaned for their reception. 

The nurse should assure herself that everything is ready and 
in its place at least three weeks before the expected date of the 
labor, for nothing is more annoying to the physician than con- 
fusion and delay after labor has begun. Moreover, if the proper 
supplies are not at hand when they are wanted, and any emer- 
gency arises, it is impossible to manage the case in an aseptic 
manner, and the health, if not the life, of the patient may be 
greatly endangered. 

All the articles mentioned above can be prepared by the 
patient or nurse, but many persons prefer to buy the necessary 
supplies and dressings, and there is a variety of " maternity 
outfits" on the market ranging in price from $3.00 to $50.00. 

The outfit described here, but without the bulky articles, is 
made up by Johnson & Johnson, of New Brunswick, New Jersey, 
under the name of the " Cooke Maternity Outfit," and may be 



128 A NURSE'S HANDBOOK OF OBSTETRICS. 

ordered through any druggist or dealer in surgical supplies. It 
contains : 

Six abdominal binders, one and three-quarters bv three-quar- 
ters yards. 

Two obstetrical pads. 

Twenty-four sanitary pads. 

Three papers safety-pins, assorted sizes. 

One nail-brush. 

One tube vaseline. 

Two packages absorbent cotton. 

One bottle synol soap. 

One bottle alcohol (ninety-five per cent.). 

One bottle olive oil. 

One bottle solution of boric acid. 

One bottle bichloride tablets, for making solutions. 

Tape for tying the umbilical cord. 

Wipes for cleansing the infant's eyes and mouth. 

One cake castile soap. 

One box talcum powder. 

Two sponges for the infant, larger for the body, smaller for 
the face and neck. 



XII 

The Mechanism of Labor 

In studying the mechanical phenomena that accompany de- 
livery it is necessary to consider three factors, — the " passenger' 
(foetus) ; the "passages" (uterus, vagina, and vulva) ; and the 
forces of labor, which impel the " passenger" through the " pas- 
sages'' into the world. The forces of labor may be subdivided 
into two classes, — the expulsive forces, situated in the muscular 
fibres of the uterus and assisted by the powerful abdominal mus- 
cles ; and the resistant forces, which consist of the resistant 
powers of the tissues composing the cervix, the vaginal floor, and 
the perineum. 

These two classes of forces must be very nearly balanced, 
but with the expulsive force slightly in excess, if the labor is to 
be normal. If the resistant forces are in excess, labor cannot 
occur without operative interference, and if the expulsive force 
greatly exceeds the resistant force a precipitate labor will result, 
with probable severe laceration of the maternal soft parts and 
with great danger to both mother and child. 

The "passenger" (foetus) lies in the womb in a state of 
complete flexion, and we have to consider its presentation and 
its position, for unless these are both normal, or can be made 
normal, the labor cannot be normal. 

Presentation refers to that part of the foetus which " pre- 
sents" at the brim of the pelvis at the beginning of labor. For 
example, if the head lies in the brim ready to come down into 
the vagina the case is said to be one of " vertex" presentation ; 
while if the breech is first to appear, it is called " breech" pres- 
entation. 

Position has to do with the relation of the presenting part 
to the pelvis. Thus, in a vertex presentation, the back of the 
head (occiput) may point to the front or to the back of the 

9 129 



130 



A NURSE'S HANDBOOK OF OBSTETRICS. 




-Vertex presentation. (Bumm.) A, left occipitoanterior (L. O. A.) ; B, 
nghfocdpUo-anterior P (R. O. A.); C right occipito-posterior (R. O. P.); D, left occiprto- 
posterior (L. O. P.)« 



VERTEX PRESENTATION. 131 

pelvis. The occiput never points exactly forward or backward 
111 the median line, but is always directed to one side or the 
other of the middle. Consequently we may have any one of 
four positions in a vertex presentation, — namely : 

Occiput to left of front, or left occipito-anterior. ("L. 
O. A.") 

Occiput to right of front, or right occipito-anterior. ("R. 
O. A.") 

Occiput to right of back, or right occipito-posterior. (" R. 
O. P.") 

Occiput to left of back, or left occipito-posterior. ("L. 
O. P.") 

Vertex presentations (Fig. 41) occur in nearly all cases 
(ninety-seven per cent.), probably because the head is the 
heaviest part of the foetus, and so has a natural tendency to sink 
to the bottom of the uterus. The position of more than half 
( seventy per cent. ) of all vertex presentations is with the occiput 
to the front and to the left of the median line. This is called 
the " left occipito-anterior" position of the vertex, and is usually 
abbreviated by physicians as " L. O. A.," an expression with 
which the nurse will become very familiar in the course of her 
obstetrical training. " L. O. A." is by far the most common of 
all positions, and as, for this reason, it may be regarded as the 
normal position of the foetus in utero it is also occasionally styled 
the " first" position. 

In the same way, the other positions of the vertex, " R. O. 
A.," " R. O. P.," and " L. O. P.," are sometimes called, respec- 
tively, the second, third, and fourth positions of the vertex. 

In order that the vertex, or top of the head, may present, the 
head must be "flexed;" that is, tipped forward on the chest; 
and this flexion increases as labor progresses until the head has 
passed through the brim of the pelvis and is in the vagina 
(Fig. 42). 

While the head is descending in this way the occiput is grad- 
ually rotated forward (in anterior cases) until it lies in the 
median line in front and under the symphysis pubis. This rota- 
tion is due to the action of the funnel-shaped walls or "inclined 



132 



A NURSE'S HANDBOOK OF OBSTETRICS. 



planes" of the pelvis, which turn the head in the right direction 
much as a ball may be rolled down a winding gutter or trough. 



Fig. 42. — Flexion of head during second stage. (Pinard and Varnier.) The shaded 
head shows the minor flexion at the beginning of labor, and the unshaded the stronger 
flexion as labor progresses, oc, oc', occiput. 



As soon as the completely flexed head has passed through 
the pelvic brim and lies with the occiput under the symphysis, 
the process of " extension" begins. The chin is now raised from 
the infant's chest and sweeps down over the posterior vaginal 
wall and perineum into the world ( Fig. 43 ) . The occiput, which 
has been practically stationary under the symphysis, where it has 
acted as a pivot during the extension of the head, is now born, 
and the most difficult part of the labor is over. 

Almost immediately after the birth of the head it is again 
rotated in a quarter-circle, so that its back points to the same 
side that it did at the beginning of labor. This is called " exter- 
nal rotation" or <( restitution" (Fig. 44), and is caused by the 
action of the inclined planes of the pelvis on the shoulders of 
the infant, which are rotated like the head as they pass down 
through the pelvic canal. " External rotation" is of interest 
to the physician, as it enables him to verify his diagnosis of posi- 
tion, made at the beginning of labor. If the case is " L. O. A.," 



FLEXION AND EXTENSION. 



133 



the back of the head will, after external rotation, point to the 
left side of the mother, as it did before labor began. 




Fig. 43. — Extension of the head in anterior presentations of the vertex. (Garrigues.) 

We have, then, to consider during labor in anterior positions 
of the vertex (" L. O. A." and " R. O. A."), Flexion, Rotation, 
Extension, and Restitution of the head, all accompanied by De- 
scent (Fig. 45). 

If, instead of being Hexed, the head, in a vertex case, is ex- 
tended or tipped backward on the body of the child at the begin- 
ning of labor, the case will become one of "face" presentation. 
This is one of the most serious complications that can arise in 
connection with labor, for if the face cannot be changed by the 
physician into a vertex presentation, the child cannot be born, 
except in rare instances, without operative interference of one 
kind or another (Fig. 46). 



134 



A NURSE'S HANDBOOK OF OBSTETRICS. 



"Brow" presentations are those midway between face and 
vertex, and occur when the head is neither fully flexed nor fully 




Fig. 44. — External rotation. (Garrigues.) The case was originally L. O. A., and the vertex 
now points to the left thigh of the mother. 

extended (Fig. 47). Because of the ''wobbly" position of the 
head, brow cases usually convert themselves into either face or 
vertex presentations before labor is very far advanced. Hap- 
pily, the most common outcome of a brow case is spontaneous 
conversion into a vertex presentation. 

Either a brow or face presentation may occur in any one of 
four positions, named according to the direction in which the 
chin points (Fig. 48). 

Breech presentations are those in which the breech instead 
of the vertex presents at the pelvic brim. They are fairly com- 



INTERNAL ROTATION AND EXTENSION. 135 

mon, and the chief difficulty in their management lies in the 
fact that, during the descent of the body, the arms of the foetus 
are liable to become extended above the head and interfere 




Fig. 45. — Internal rotation and extension. (Tarnier and Chantreuil.) 

seriously with its passage through the pelvis (see Fig. 69). 
Breech presentations occur in any one of four positions, named 
according to the direction in which the sacrum of the infant 
points (Fig. 49), thus: 

Left sacro-anterior (" L. S. A.") 

Right sacro-anterior (" R. S. A.") 

Right sacro-posterior (" R. S. P.") 

Left sacro-posterior ("L. S. P.") 

In breech cases the infant often passes meconium from its 
rectum during the course of the labor, and if, after the mem- 
branes are ruptured and the liquor amnii has escaped, the nurse 
finds a black, tarry discharge coming from the patient's vagina, 
she may very properly suppose that the case is one of breech 
presentation. 



136 A NURSE'S HANDBOOK OF OBSTETRICS. 




Fig. 46.— Shape of head of child 
born in face presentation. (Char- 
pentier.) 




Fig. 47.— Shape of head of 
child born in brow presentation. 
(Charpentier.) 




Fig. 48.— Face presentation. (Bumm.) 



BREECH PRESENTATION. 



137 





Fig. 49.— Breech presentation. (Bumm.) A left sacroanterior; B right sacro-posterior. 




Fig. 50.— Prolapse of arm in transverse presentation. (Tarnier and Chantreuil.) 



138 A NURSE'S HANDBOOK OF OBSTETRICS. 

Other presentations, all of which are very rare, are those of 
the foot, arm (Fig. 50), or shoulder. 

The study of the special mechanism of the different presenta- 
tions and positions is one of great interest, but the brief outline 
given of the mechanism in anterior positions of the occiput is 
all that directly concerns the nurse. 

All other cases are more or less abnormal, and, as their 
progress is usually slow, their management must be left entirely 
in the hands of the medical attendant. 



XIII 

The Phenomena of Labor 

Labor occurs at the end of pregnancy, and is also known by 
the various names of "delivery" "confinement" "lying-in" 
and "parturition." 

The usual time for labor to take place is two hundred and 
eighty days (ten lunar months, or nine calendar months) after 
the occurrence of conception. This period varies somewhat, and 
it is possible for a child to be born and live after only about two 
hundred and twenty days of utero-gestation. These cases are, 
of course, extremely rare, and it goes without saying that the 
more nearly the pregnancy reaches its normal duration the better 
will be the development of the child and the better its chances for 
living. The only exceptions to this rule are in cases where the 
mother is suffering from a disease that greatly imperils the life 
of the child, or where the child is very large or the pelvis very 
small, and the induction of premature labor exposes the infant 
to less risk than would a difficult operative delivery at full term. 

The popular belief that a seven-months baby has better 
chances for life than one born at eight months is the most arrant 
nonsense. It probably arises from the fact that a child born at 
seven months is positively known to be premature, and so re- 
ceives the most careful attention after birth, while an eight- 
months baby is so nearly a full-term infant that its prematurity 
is often overlooked and it receives no special attention, and 
may die from some inadvertent neglect of small but important 
details. After it is dead the fact that it was one month prema- 
ture is brought out and commented upon. 

In other cases the pregnancy may exceed its usual duration 
of two hundred and eighty days, but probably it never goes more 
than three weeks over term under any circumstances, and three 
hundred days may be regarded as the extreme limit. In France 
this point has been made a matter of legislation, and an infant 

i39 



lzj.O A NURSE'S HANDBOOK OF OBSTETRICS. 

born at any time within three hundred days after the death of 
its mother's husband is regarded by law as legitimate and enti- 
tled to property rights in the father's estate, while one born even 
twenty-four hours after this period is deprived of the right of 
inheritance. 

The method of calculating the probable date of labor is men- 
tioned in another chapter, but it may also be referred to here. 

Count back three months from the first day of the last men- 
struation, and add seven days. This will give a date to be 
regarded as the middle of a period of two weeks during which 
the labor may be expected to occur. Thus, if the woman's last 
menstruation began September 9, count back three months, to 
June 9; add seven days, making June 16, and tell her that she 
will probably be confined some time between June 9 and June 
23, of which period June 16 is the middle. Of course, this 
method is approximate at best, and when menstruation has con- 
tinued in the early months of pregnancy it has no value whatever. 
Under such circumstances the probable date of the labor will 
have to be computed by the physician after a careful considera- 
tion of all the early signs of pregnancy. 

The cause of labor is probably due to the fact that at the 
end of pregnancy the uterus is stretched to its greatest possible 
extent, while the foetus continues to grow larger. The muscular 
fibres of the uterus resent this over-distention and put an end to 
it by contracting and forcing the foetus out of the womb. This 
theory is borne out by the fact that in twin pregnancies, or in 
other cases where the uterine contents is unusually large, prema- 
ture labor is very likely to occur, showing that when a certain 
degree of distention is reached labor will begin. 

The premonitory symptoms of labor are usually well 
marked in the case of a first pregnancy, but in some instances, 
and especially with women who have borne children, they may 
be entirely absent. When they do occur they may begin at any 
time up to two, or even three, weeks before the actual onset of 
labor. They are due chiefly to the sinking down of the uterus 
into the pelvis preparatory to the engagement of the fetal head 
in the pelvic brim. This relieves the pressure on the diaphragm 



STAGES OF LABOR. 141 

and so lessens or stops the cough, dyspnoea, and other unpleasant 
symptoms of the last weeks. While the sinking of the uterus 
relieves the pressure above the diaphragm, it increases that on 
the pelvic viscera, causing constipation and irritability of the 
bladder. On the whole, however, the woman feels more com- 
fortable than she did before the sinking of the womb. In addi- 
tion to the symptoms due to alterations in pressure there are 
occasional slight uterine contractions occurring at irregular inter- 
vals and causing the woman no discomfort beyond the sensation 
of faint and indefinite cramp-like pains in the abdomen. 

Labor is divided, for convenience of description, into three 
distinct stages. 

The first stage begins with the first true labor-pain and ends 
with the complete dilatation of the os uteri. 

The second stage begins with the end of the first and ends 
with the birth of the child. 

The third stage begins with the end of the second and ends 
with the delivery of the placenta and membranes. 

In normal cases the first stage is longer than the second and 
third together, for after the os is fully dilated the labor pro- 
gresses rapidly. 

Labor-pains are merely the contractions of the uterine mus- 
cle, and are called " pains" because of the suffering that accom- 
panies them. The incorrectness of the term is evident when one 
occasionally hears a woman say, " I always have easy labors ; 
my pains never hurt me at all." 

The Phenomena of the First Stage. — The pains are 
short, slight, and separated by long intervals, usually about half 
an hour. They do not cause the patient any particular discom- 
fort, and are not accompanied by any straining of the abdominal 
muscles. What little pain there is is located in the back, and 
the patient is usually on her feet and walking about. If the 
woman has never borne a child or seen a labor, she is commonly 
in rather a jocular frame of mind, and often expresses great 
contempt for the reputed suffering of child-birth. 

A little later, however, the entire picture changes. The pains 
last longer and are more severe, and recur at more frequent 



142 A NURSE'S HANDBOOK OF OBSTETRICS. 

intervals. The patient is still walking about, but at the begin- 
ning of each pain she grasps a chair-back or some other piece of 
furniture, and, leaning heavily against it, " grunts" audibly when 
the pain is at its height. Even now the pains are not specially 
severe, and between them the patient is usually cheerful and still 
of the belief that labor is not such a terrible thing after all. As 
the hours go by the pains become more and more frequent, until 
they are only five or six minutes apart, while at the same time 
they last longer and are more severe. The patient is now tired 
and fretful, and begins to complain bitterly that the end will 
never come and that something must be done to relieve her. 
Her entire disposition changes and her face bears an expression 
of anxiety and dread. She may be nauseated, or even vomit, 
and her bowels and bladder are emptied every few minutes. At 
the acme of each pain she usually moans slightly, and in the 
intervals she says little, except to ask for water or other attention 
and complain of the slow T progress she is making. 

This picture indicates that dilatation of the os uteri is nearly, 
if not entirely, complete, and the nausea and vomiting are favor- 
able symptoms, for they are accompanied by relaxation of the 
tissues. 

At or about this time the amniotic sac, which, from the begin- 
ning of labor, has been forcing its way down through the os 
and dilating it in every direction, usually ruptures and the fluid 
escapes with an audible gush. 

Even without a vaginal examination it is usually easy to tell 
from the appearance of the patient that the first stage of labor 
is at an end. It may have lasted anywhere from one to twenty- 
ifour hours, and is always protracted if the membranes rupture 
before dilatation of the os is complete. 

The Phenomena of the Second Stage. — The patient is 
now in bed and the pains are severe, long (fifty to one hundred 
seconds), and occur at intervals of every two or three minutes. 

The abdominal muscles are now brought into play, and as a 
pain occurs the woman " bears down" with all her strength, so 
that her face becomes red and even cyanotic, and the large vessels 
in her swollen neck pulsate violently. At the beginning of a pain 



STAGES OF LABOR. 143 

she begins to mumble fretfully, and as it reaches its height she 
concentrates all her voice into a peculiar frenzied cry, so charac- 
teristic of labor that one who has ever heard it would recognize 
it at once, even amid the most improbable surroundings. 

With it all, however, the woman does not complain as much 
now as during the first stage, and, instead of plying the nurse 
and physician with impatient demands for relief, she devotes her 
entire energy to delivering herself, and at times seems almost 
oblivious of her surroundings. 

Towards the end of the second stage, when the head is well 
down in the vagina, its pressure often causes small particles of 
fecal matter to be expelled from the rectum at the occurrence of 
every pain. 

The pains are now occurring so rapidly that there is scarcely 
any interval between them, and finally, with a sharp, agonized 
shriek, the head is born and the mother lies gasping for breath 
and sighing contentedly. One or two more pains are enough to 
effect the birth of the body, and practically all of the labor 
is over. 

The Phenomena of the Third Stage. — Towards the end 
of the second stage the placenta has become detached from the 
uterine wall and lies loosely in the womb or partly in the vagina. 
After the birth of the child the uterus contracts firmly on the 
placenta, and there is a period of from ten to thirty minutes in 
which no pains occur and the exhausted muscles rest from their 
exertions. A little blood trickles from the vagina, and finally, 
with one short and not very severe pain, the placenta and mem- 
branes are expelled and the uterus contracts firmly and per- 
manently. 

The total duration of labor in normal cases averages 
about ten hours, the greater part of which time is taken up by 
the first stage; but the time may vary from one or two to even 
twenty-four hours without being in any way injurious to the 
patient. 



XIV 

Preparations for Labor 

These begin with the making or purchase of the supplies 
described in Chapter XL and end with the selection, furnishing, 
and preparation of the lying-in room. 

The room in which the confinement is to take place is to be 
chosen with great care, for it must serve first in the capacity of 
a hospital operating-room and afterwards meet the requirements 
of a cheerful and comfortable bedchamber, in which every want 
of a convalescent patient can be met promptly and satisfactorily. 
For these reasons there are two prime factors in the choice of 
the room which can never be safely overlooked. First, it must 
be scrupulously and surgically clean ; and second, it must be 
bright, spacious, properly lighted, well heated, and thoroughly 
ventilated. 

The nurse is, of course, limited in her selection of a room for 
this purpose to the possibilities of the house in which the patient 
resides, but no room is too good for the business in hand, and 
she is at perfect liberty to make use of even the parlor or dining- 
room if it seems best suited to her needs. Naturally, the nurse 
will avoid putting the family to any unnecessary inconvenience, 
but her first thought must always be in the interest of her patient. 

The ideal lying-in room is one that is large, sunny, provided 
with an open fire-place, and" with a well-equipped bath-room 
adjoining, or at least on the same floor. It should be situated in 
a part of the house that is quiet and as far as possible from the 
odors of the kitchen and other unpleasant features. 

The nurse must make sure that the room has not been occu- 
pied within at least six months by a patient suffering from any 
contagious, infectious, or suppurative disease, and if such is 
found to have been the case the room is to be condemned and 
another, though possibly a less convenient one, chosen in its 
place. If, for any reason, it is impossible to make use of another 
144 



FURNITURE OF LYING-IN ROOM. 



145 



room, the infected one is to be thoroughly disinfected with for- 
malin * and then entirely dismantled, and repainted and re- 
papered throughout. 

In any event, the lying-in room is to be thoroughly cleaned 
and all the wood-work wiped off with damp cloths at least two 
weeks before the expected date of the labor; and all curtains, 
draperies, portieres, and other articles that can collect dust are 
to be banished. In the same way, all unnecessary furniture is 
to be removed and only enough left to make the room com- 
fortable and cheerful. 

It is well to have the carpet taken up, especially if it is old 
or at all soiled, but in some cases this may be avoided by covering 
the floor with muslin sheeting, well tacked down to prevent its 
slipping; or even by having the carpet wiped off with Piatt's 
Chlorides after it has been well swept. As an argument in favor 
of taking up the carpet, when objection is raised on the score of 
unnecessary inconvenience, the patient may be reminded that if 
this is done the carpet will be in no danger of damage from the 
possible spilling of blood or solutions. 

In short, the room is to be as clean and free from dust- 
collecting and germ-breeding articles as it is possible to make it, 
and the nurse who has been thoroughly drilled in aseptic and 
antiseptic methods will understand what is required without 
further argument. 

The furniture of the lying-in room should consist of, — 

A bed for the mother. 

A bed for the nurse (unless she is to occupy another room). 

A bed, or bassinette, for the infant. 

A bureau, or chiffonier. 

A strong but light table. 

A wash-stand, properly equipped. 

An extra slop- jar, or pail. 

Two or three chairs. 



* This can be done conveniently with " Lister's Formaldehyde Fumi- 
gators," manufactured by Johnson & Johnson, of New Brunswick, New 
Jersey. 

10 



146 A NURSE'S HANDBOOK OF OBSTETRICS. 

It is undesirable to have running water in the room, because 
of possible danger from defective plumbing, and if, by chance, 
there is a stationary basin, the nurse should plug up the little 
holes of the overflow with corks or putty, and keep the bowl half 
full of water. If a bath-room or dressing-room adjoins the 
lying-in chamber, with a door between, it is a great convenience. 

The infant should never, under any circumstances, be allowed 
to sleep with its mother, and its bed may be either the crib that 
it is to occupy during its childhood or a bassinette (Fig. 51), 
designed for use only in its infancy. In emergency cases, where 
neither of these is at hand, a temporary bed may be made for the 
baby out of a box, a large trunk-tray, or a bureau drawer; or 
it may sleep on a couch or in a large arm-chair. Two ordinary 
cane-seated chairs, placed against the wall and with a hair 
pillow or cushion for a mattress, make an excellent temporary 
bed. 

Bassinettes may be purchased in any style and at any price 
that suit the taste and the pocket-book of the purchaser, or a 
very pretty one may be made at home with a clothes-basket as a 
basis and barrel-hoops wound with ribbon to support the dra- 
peries. As a rule, the chief objection to the bassinette is its 
great depth, and as an infant needs plenty of fresh air it is not 
benefited by spending the greater part of its time at the bottom 
of a deep basket, surrounded and entirely shut in by curtains 
and hangings. In selecting or designing a bassinette, the top 
of the infant's bed should never be more than four inches below 
the top of the basket or framework, and if the nurse finds one 
ready for use in which this depth is exceeded she should raise 
the level of the bed by placing under it a folded blanket or- a 
pillow. The bed should be of hair and never of feathers, or the 
infant will sink down into it and be hot and uncomfortable from 
the first. 

The mother's bed should be the best that the house affords, 
for the period of convalescence after labor is the more trying 
to the patient the more nearly it is normal, and unless her bed 
is a comfortable one it is often a very difficult matter to persuade 
her to keep in it for the required number of days. The springs 




Fig. 51. — Bassinette. (Davis.) 



PREPARATION OF BED FOR LABOR. 147 

should be good and the mattress firm and solid so that it will 
sink down in the middle as little as possible. 

Unless it is absolutely necessary this bed shmild never be the 
one in which the woman is confined, and for this purpose a cot 
or broad. Hat couch is to be provided, which can afterwards serve 
as the bed for the nurse if no other is available. If the labor 
takes place in an ordinary double bed, it is extremely difficult 
for either the physician or the nurse to " get at" the patient 
conveniently, on account of its width and the presence of the 
head-board and foot-board ; while if any operative work becomes 
necessary or an emergency arises, the awkwardness of the situa- 
tion is more marked than ever. On the other hand, if a cot or 
couch is used, the patient is accessible from all sides, and the 
case can be managed as easily and conveniently as on a hospital 
operating-table. An acceptable, though by no means necessary, 
addition to the cot or couch is the use of two blocks of wood or 
two strong boxes on which it can stand, and which will raise 
it to the height of a table or hospital bed. 

The preparation of the bed or beds depends upon whether 
one or two are to be used. If but one bed is provided it must 
be so arranged that, after the labor, it can be rearranged quickly 
and easily and put into a clean and comfortable condition without 
disturbing the patient to any great extent. The best way to 
accomplish this is to first prepare the bed as it is to be during 
the puerperium and then add the necessary preparations for the 
labor. 

The mattress is to be supported from below by means of 
boards slipped in between it and the springs, so that it will be 
perfect}* firm and level during the labor and not sag down in 
the slightest degree. Boards may be made expressly for this 
purpose, or table-leaves or slats from another bed may be used. 
They are to lie crosswise of the bed, at a point directly under 
the patient's buttocks, and should be removed at the conclusion 
of labor. Their use facilitates all the work about the patient, and 
by keeping the mattress perfectly flat prevents the blood and 
other discharges from collecting in a pool under the patient's 
back. 



i 4 8 



A NURSE'S HANDBOOK OF OBSTETRICS. 



The mattress is now to be covered with a piece of rubber 
sheeting pinned securely at the sides and corners so that it will 




Fig. 52.— Preparation of bed for labor. First stage. 




Fig. 53.— Preparation of bed for labor. Second stage. 



not slip ; over this is to be placed a white sheet pinned in the 
same way, and over this a draw-sheet, also carefully pinned 



PREPARATION OF PATIENT. 149 

(Fig. 52). This is the correct arrangement of the sheets for 
the puerperium, and they must be protected for the labor by 
covering them with another rubber sheet or " enamel cloth " and 
white sheet, both of which are to be pinned securely all around 

(Fig- 53)- 

After the labor is over the uppermost white sheet and rubber 
sheet are removed, and the patient lies on the white sheet and 
draw-sheet underneath. 

If two beds are used, the mattress of the cot on which the 
labor is to occur is supported with boards, as in the first instance, 
and protected with a rubber sheet covered with a white sheet, 
both of which are securely pinned on all sides. 

The other bed is then made ready in the manner already de- 
scribed with rubber sheet, white sheet, and draw-sheet. On the 
draw-sheet should be placed one of the obstetrical pads from the 
maternity outfit, in such a position that it will come directly 
under the patient's buttocks when she is laid in the bed. 

Unless the various coverings are carefully and securely 
pinned they will become greatly disordered by the tossing and 
turning of the patient, and in protracted cases they may even 
be torn entirely from the mattress and cast on the floor. 

The nurse should see that the provisions for lighting the 
room at night are ample, and that it is warm and comfortable in 
every way. 

Last Moments. — The physician should be summoned as 
soon as labor-pains begin, unless he has given definite instruc- 
tions to the contrary. Some physicians prefer not to be called 
to a case until, in the opinion of the nurse, the first stage is 
nearly at an end, but even under these circumstances it is better 
that he should know that the woman is in labor, so that he will 
be prepared to respond promptly to the second call. 

After the messenger has been despatched for the doctor the 
patient should be given an enema of soapsuds, one pint, and 
spirits of turpentine, one teaspoonful. This will effectually empty 
the lower bowel, and render the labor not only easier but infi- 
nitely more cleanly, and must never be neglected. 

The patient should now receive a thorough general bath with 



150 A NURSE'S HANDBOOK OF OBSTETRICS. 

plenty of soap and warm water, either in the tub or, if the pains 
are severe, in the form of a sponge-bath. After the bath her hair 
is to be well brushed and braided in two braids, and she is to 
be dressed in a clean night-gown, clean stockings, and slippers, 
over which she will wear a wrapper or bath-robe that can be 
slipped off and on easily. 

Some authorities object to the use of the tub-bath at the 
onset of labor, in the belief that there is danger of the entrance 
of unsterile water into the vaginal canal. This has always 
seemed an unnecessary precaution to the author, but the nurse 
should make it a point to learn the wishes of the attending physi- 
cian in this matter and act in accordance with his views. If 
objection is made to the general bath the patient should be 
caused to stand in the tub, which is to be partly filled with 
warm water so that her feet will not be chilled, and then given 
a thorough sponge bath, after which she may be showered, 
either with a spray or with water poured over her from a 
pitcher. 

"While the patient is occupied with her bath the lying-in 
chamber is to be prepared for the labor, and the bed, or beds, 
properly made up. If the patient has been sleeping in the bed in 
which she is to be confined it is to be completely dismantled and 
supplied with clean bedding throughout. A chair is to be placed 
at the right side of the bed, facing the head, for the physician, 
and a table (preferably a low cutting-table) covered with clean 
white towels should stand within easy reach of his right hand. 
The slop- jar, or pail, is to be placed so that the apron of the 
physician's Kelly pad will drain into it (Fig. 54). 

The patient's genitals should now be bathed with a solution 
of Tincture of green soap (two drachms to the pint) made with 
boiled water, and the vulva covered with a clean sanitary pad 
held in place by a band about the waist. 

From this moment the use of the water-closet must 
be forbidden absolutely. Evacuations of urine and faeces are 
to be received in a clean vessel, which is to be removed at once 
from the room, emptied, cleaned thoroughly, and returned with 
as little delay as possible. The vulva pad, which must, of course, 



£■ MB 




FINAL ARRANGEMENTS. 151 

be removed when the rectum or bladder is emptied, is in every 
instance to be replaced by a fresh, clean one. 

The nurse should see that the lying-in room is warm, well 
lighted, and arranged according to directions ; that all supplies 
are at hand and in order; that there is an ample supply of cold 
boiled water ; that there is a good fire in the kitchen stove, unless 
a gas-stove is available, and that plenty of water is actually boil- 
ing : that the instructions relative to the patient have been con- 
scientiously carried out ; and, lastly, that all children and other 
unnecessary individuals have been gotten out of the way. 



XV 

The Conduct of Labor 

Normal labor may be defined as labor which is terminated 
without artificial assistance and which leaves the mother in good 
condition, beyond a slight feeling of exhaustion and sense of 
fatigue. It might perhaps better be termed " unassisted labor," 
for surely an easy and rapid breech delivery, which occasionally 
occurs and which is in one sense to be regarded as a distinct 
abnormality, is to be preferred to a protracted and difficult vertex 
case which subjects the mother to great suffering and more or 
less shock. 

For practical purposes, then, so far as the nurse is concerned, 
we may regard as normal any labor which is accomplished within 
a reasonable length of time without manual or instrumental 
interference. 

In the cases most likely to come under the care of the trained 
nurse in private practice she will often be summoned several 
days or even weeks before the onset of labor, and so will be in 
a position to observe its phenomena from the very first. 

It is assumed that all the preparations named in Chapter 
XIV. have been made, and that everything is in readiness for the 
expected event. 

For a varying period before the establishment of true labor- 
pains the patient will often suffer from so-called " false pains," 
and the nurse must be able to distinguish between them and 
effective uterine contractions. 

False pains may begin as early as three or four weeks 
before the termination of pregnancy, and they are merely exag- 
gerations of the intermittent uterine contractions which occur 
throughout the entire period of gestation, combined with the 
effects of pressure on the abdominal tissues as the uterus and its 
contents settle down in the pelvis. They occur at decidedly 
irregular intervals, are confined chiefly to the lower part of the 
152 



TRUE LABOR-PAINS. 153 

front and sides of the abdomen and groin, never extending 
around to the back, and are short and ineffective. They are 
more annoying than painful, and are never accompanied by any 
actual " bearing-down" sensation. The primigravida often re- 
gards them as true labor-pains, and marvels at the ease with 
which she bears them, but the woman who has borne children 
or the experienced obstetric nurse is seldom if ever misled by 
them. 

True labor-pains occur with a regularity that is almost 
perfect, and if they are timed by the clock it will be found in the 
majority of cases that, at the beginning, they will occur at inter- 
vals of about half an hour and that the periods between them 
will be exact almost to a minute. In timing the pains in this 
way the nurse should not let the patient know what she is doing, 
as the knowledge may have a suggestive influence on their fre- 
quency. 

The gradation between false and true pains is an almost im- 
perceptible one, the first indication of the appearance of true 
pains being usually the establishment of this regularity in their 
recurrence. Soon, however, the true pains begin to take on their 
characteristic qualities. They become longer and somewhat 
more painful. Beginning in the back they extend around to 
the front, the sensations in the front of the abdomen remaining 
after those in the back have ceased, and they are accompanied 
by a distinct " bearing-down" feeling. True pains cannot be 
said to be especially painful in the early part of the first stage, 
but the patient usually realizes fully that her labor has begun, and 
her face often wears a somewhat anxious expression, with a 
slight flushing and drawing of the features at the acme of the 
pain. 

As soon as the nurse has decided, from the character of the 
pains, that labor has actually commenced, she should notify the 
physician in charge of the case. It does not necessarily follow 
that he will respond personally to this notification, but it is 
proper that he should know that his patient is in labor, so that 
he can arrange his time and engagements and be ready to answer 
promptly the second and peremptory call. 



154 A NURSE'S HANDBOOK OF OBSTETRICS. 

As soon as the physician has been notified the nurse should 
begin to arrange the room for the labor, being guided as to haste 
by the frequency of the pains. 

The room is to be warm (70 to J2° F.), well lighted and 
well ventilated ; hot and cold sterile water and provision for 
boiling the physician's instruments are to be provided; and the 
needed supplies described in Chapter XL are to be arranged in 
a convenient manner and place. The patient is to receive an 
enema of soapsuds, one pint, and spirits of turpentine, one tea- 
spoonful, and is then given a warm bath, either in the tub or 
by sponging, as the circumstances will permit. The external 
genitals are to be cleansed with special care, and the pudendal 
hair, if long and abundant, must be clipped short with scissors. 

The patient's hair is to be braided neatly in two braids ; she 
is dressed in clean night-gown, slippers, and bath-robe ; and a 
vulva pad is applied and pinned to the night-gown or to a band, 
to protect the parts and absorb any discharge that may escape 
from the vagina. 

From the beginning of the true pains the patient is not to be 
allowed to use the water-closet wider any circumstances what- 
ever, and if the enema of soapsuds and turpentine has been 
effective, she will have no occasion to do so except to empty the 
bladder. This need, however, will usually be frequent, and the 
urine is to be voided in a clean vessel, which is to be removed at 
once from the room, cleaned thoroughly, and returned with as 
little delay as possible. It will, of course, be necessary to remove 
the vulva pad when the urine is voided, and after the act has 
been accomplished the external genitals are to be bathed care- 
fully and a fresh vulva pad applied. A pad that has once been 
removed must never be replaced, no matter how clean it may 
appear to be, and there can be no exception to this rule because 
of the danger of carrying infection to the vulva. 

The woman is to be encouraged to keep on her feet the 
greater part of the time, to favor descent of the head into the 
pelvis, and the nurse should endeavor to make this trying ordeal 
as light as possible by cheering words and a hopeful manner. 
The patient is to be dissuaded from attempting to help herself 



TRUE LABOR-PAINS. 1 55 

by voluntary straining of the abdominal muscles, for such efforts 
do no good at this time and only exhaust her and wear out her 
strength ; and it is even a good plan to keep up her energy 
during the first stage by providing some light refreshment, such 
as tea and toast or soda-biscuits, of which she can partake when- 
ever she feels so disposed. 

If the membranes rupture in the first stage the danger of 
prolapse of the cord must be kept in mind, and the physician 
should be notified immediately, but this should be done without 
the patient's knowledge, for, especially if it is her first labor, the 
accident is apt to cause her great alarm. She should be informed 
at once of the nature of the watery discharge, and assured that 
it is a perfectly natural phenomenon, and of no consequence 
whatever. If her night-gown or other garments have become 
soaked with amniotic fluid, they must be replaced at once with 
dry clothing. 

When the pains occur as often as every five minutes the phy- 
sician is to be summoned peremptorily, and even sooner than 
this if he lives at a considerable distance from the patient or in 
case there is any difficulty in getting word to him. Many phy- 
sicians give the nurse positive orders as to when they wish to 
be called, but in the absence of any such explicit directions 
she may regard the above rule as a safe guide in the majority 
of cases. 

This degree of frequency in the occurrence of the pains is a 
fair indication of the beginning of the second stage of labor, and 
when the pains take on the characteristic features of those, of the 
second stage the diagnosis of the condition is not at all difficult. 
The pains of the second stage are longer, much more severe, 
and the patient's face is suffused with blood until, at the height 
of the pain, it is almost cyanotic, while the neck swells and 
the large blood-vessels stand out like knotted ropes and pulsate 
violently. 

As soon as it is apparent that the patient is in or near the 
second stage of labor she is to be put to bed, for at this time the 
os uteri is, of course, fully dilated, and if she is allowed to 
remain on her feet precipitate labor may occur. As a rule, the 



156 A NURSE'S HANDBOOK OF OBSTETRICS. 

patient is quite willing to go to bed when this period of labor is 
reached, and in many cases she is unable to keep up any longer 
even if she were allowed to do so. 

The nurse should have ready, on the arrival of the physician, 
hot water, soap, and nail-brush for the disinfection of his hands, 
antiseptic solution (usually bichloride solution, 1 to 2000), and 
sterile vaseline or lubrichondrin. As many physicians, unfor- 
tunately, neglect to provide themselves with an apron or gown, 
the nurse should also have in readiness a small clean sheet, which 
can be pinned around his neck and again about the waist, making 
a fairly good substitute for an operating-gown. 

After the arrival of the physician he will, of course, take 
charge of the further management of the case, and, if the patient 
is still on her feet, decide when she is to be put to bed. 

If the case is at all advanced the physician will wish to make 
a vaginal examination at once, in order to determine the amount 
of dilatation of the cervix and inform himself as to the progress 
that the woman has made, and while he is disinfecting his hands 
the nurse will prepare the patient for examination. 

The woman is to lie on her back, on the right side of the bed 
near the edge, covered with two clean sheets, each folded in half 
and arranged as follows : one sheet is to lie across the bed, cover- 
ing her lower limbs and extending from the foot-board to a 
point midway between the patient's knees and hips; the other, 
covering the rest of her body, also lies crosswise of the bed and 
overlaps the first by a few inches (Fig. 55). Before the sheets 
are finally adjusted the nurse will remove the vulva pad and 
carefully bathe the external genital organs with warm sterile 
water and Tincture of green soap, and a fresh piece of absorbent 
cotton. When the physician has completed the disinfection 
of his hands the nurse will squeeze some vaseline or lubri- 
chondrin from a collapsible tube on his index and middle fingers, 
taking care that neither the tube nor her own hand comes in 
contact with the examining fingers. The patient should now be 
directed to draw up and widely separate her knees, while the 
nurse raises the upper of the two sheets so that the physician 
can see the vulva, and holds it in such a position that it cannot 




Fig. 56. — Vaginal examination. 



PRELIMINARY EXAMINATION. 



157 



come in contact with his hands, but serves as a screen to pre- 
vent the woman from appreciating the extent to which she is 
exposed (Fig. 56). 

The writer prefers this method to the older one of covering 
the limbs and abdomen with a single sheet arranged in " horse- 
shoe" form, which is always getting in the way or becoming 
disarranged, and which, from the nature and method of its ad- 
justment, is far more suggestive to the patient than the one 
described in detail. 

If the physician's outfit contains a Kelly pad (Fig. 57), it is 
to be placed under the patient, with its apron draining into the 





Fig. 57. — Kelly pads. 



slop- jar or pail, and covered with a clean towel tucked well 
under the edges of the pad, so that it will not easily slip out 
of place. 

The nurse is to see that fresh solutions for the hands are 
always ready and at a proper temperature (ioo° F.) ; that soiled 
or bloody towels and sponges are removed at once from the 



158 A NURSE'S HANDBOOK OF OBSTETRICS. 

room, or at least kept out of sight as far as possible ; that scissors 
and tape for tying- the umbilical cord and boric acid wipes for the 
infant's eyes and mouth are ready the moment they are needed; 
and that a warm woollen blanket is provided to wrap the baby 
in as soon as it is born. 

All the instruments required are, of course, to be provided 
by the physician, and he will, on his arrival, hand over to the 
nurse whatever he thinks he may need for the particular case, 
which are to be boiled at once for fifteen minutes so that they 
will be ready the moment they are called for. In perfectly nor- 
mal cases about all that are needed are scissors, catheter, and 
douche-tube, but some physicians add to these a dressing-forceps 
and a tenaculum or volsellum. In emergency cases, when there 
is nothing at hand, an ordinary pair of clean scissors and a piece 
of new white cotton twine may be boiled and used for cutting 
and tying the cord. 

During the second stage, when the pains are most severe, the 
nurse should use every art at her command to encourage the 
patient with reassuring words and helpful assistance. A great 
deal can be done to add to the comfort of the patient by holding 
her hands at the height of the pains and, in the intervals between 
them, by rubbing her back and legs, which are often lame and 
cramped. Many women like to have something to pull on as 
the pains occur, and there is no objection to fastening a twisted 
sheet to the foot of the bed or cot, on which the patient can brace 
herself, as it were, when her suffering is most severe (Fig. 58). 

Chloroform is indicated at this stage unless there are positive 
objections to its use, and in normal cases the duty of administer- 
ing the anaesthetic usually falls to the nurse. The patient's face 
should first be well anointed with vaseline to prevent irritation 
of the skin by the drug, her clothing is to be loosened about the 
waist and neck to remove any possible interference with respira- 
tion, and false teeth, chewing gum, or any other foreign sub- 
stance that may be in the mouth is to be taken out, lest it should 
be swallowed as the patient loses consciousness. In these cases 
the chloroform is to be given to the " obstetrical degree" only. 
That is to say, it is to be administered only at the beginning of 



CONDUCT OF SECOND STAGE. 



159 



each pain and continued only as long as the pain lasts. This 
will be enough to benumb the nervous system and " take the 




Fig. 5S. — Beginning of second stage of labor. Patient bracing against chair and pulling 
on sheet at the height of a pain. 

edge off the suffering," but the patient will at no time be entirely 
unconscious, and in the intervals between the pains she will be 
perfectly rational. In operative cases, where complete surgical 





Fig. 59. — Esmarch outfit for the administration of chloroform. Dropper-bottle and mask. 



anaesthesia is required, the nurse should not be expected to 
shoulder the responsibility of administering the chloroform, espe- 



l6o A NURSE'S HANDBOOK OF OBSTETRICS. 

cially as her services will undoubtedly be needed as direct assist- 
ant to the operator, and another physician should be called in to 
act as anaesthetist. 

The best method of administering chloroform is with the 
Esmarch outfit (Fig. 59), which consists of a mask and a 
dropper bottle. The bottle is filled about half full of chloroform 
and corked, and when the stoppers are removed from both the 
little tubes that pass through the cork the contents will escape 
in a fine stream from the smaller of the two when the bottle is 
tilted to the proper angle. Before beginning the administration 
of the anaesthetic the skin of the face must be anointed with 
vaseline and the eyes shielded with a folded towel as a pro- 
tection against the irritating action of the drug. The mask is 
placed over the nose and mouth of the patient at the begin- 
ning of a pain, and the material with which it is covered is kept 
wet with the anaesthetic as long as the pain lasts (Fig. 60). 
The mask is to be removed from the face at the end of each pain 
and not replaced until the beginning of the next one, and a close 
watch must be kept of the patient's pulse and especially of her 
breathing and the general appearance of her countenance. Irreg- 
ularity of the pulse, failure of respiration, and sudden pallor are 
all danger symptoms, and the physician's attention must be called 
to them at once if they appear. 

Fortunately, the use of chloroform in obstetric practice is 
attended with little or no danger, especially when the anaesthesia 
is carried to the obstetrical degree only, and what slight danger 
there may be is minimized by the employment of the Esmarch 
apparatus, which nearly every physician carries in his maternity 
outfit. 

In the absence of the Esmarch inhaler the drug may be 
administered on a small handkerchief folded square and held 
over the face about an inch and a half from the nose. Care must 
be taken not to let the handkerchief approach the face too closely, 
for, unlike ether, which is to be inhaled in its full strength, chlo- 
roform must be diluted with a large proportion of air {ninety 
per cent.) to be taken with safety. 

When chloroform is administered at night by either gas- or 



CHLOROFORM. 



161 



lamp-light, many persons, including physicians and nurses, suffer 
from irritation of the larynx of a most severe type, due, probably, 
to the disintegration of the drug by the flame and the liberation 
of chlorine gas. This causes paroxysms of coughing which 
often make it necessary for the sufferer to leave the room, and 
in one case at least death has resulted from the violence of the 




Fig. 60. — Administration of chloroform. Patient's eyes protected by folded towel ; 
third finger of nurse's right hand taking pulse at the facial artery under the margin of 
the jaw. 



attack. The patient usually escapes because she is anaesthetized 
to such a degree that the irritating effect of the chlorine is 
unnoticed by her larynx. 

This untoward action of the drug can usually be prevented 
by keeping a good-sized cloth soaked with ammonia hanging 
from the chandelier or near the lamp. The ammonia will com- 
bine with the chlorine to form the bland and unirritating muriate 
of ammonium. Care must be taken, of course, to avoid over- 
doing the matter and making the remedy as bad as the disease 

ii 



1 62 A NURSE'S HANDBOOK OF OBSTETRICS. 

by filling the room to suffocation with the fumes of ammonia, 
but this will not happen if the ammonia cloth is merely kept wet 
with the liquid. It must hang near the light, and if any irri- 
tating effects of the chloroform are felt more ammonia must 
be used, for a sufficient quantity will almost invariably produce 
the desired result. 

Ether is not generally used as an anaesthetic in obstetric 
practice, although it finds favor with certain operators. 

The method of its administration differs materially from 
that of chloroform, and, while ether is in many ways the safer 
of the two drugs, its proper exhibition calls for greater skill 
and experience and will not, ordinarily, be required of the nurse 
unless she has had special training in its use. In emergencies, 
however, the nurse may be called upon to anaesthetize a patient 
with ether instead of chloroform, and a brief description of its 
administration may be of value in this place. 

As in chloroform anaesthesia, the patient's clothing must 
be loosened at every point, so that her respiration will be abso- 
lutely unhampered, and any false teeth or other loose objects 
must be removed from her mouth. The woman lies flat on her 
back, with no pillow under her head, and during the entire 
period of anaesthesia the neck must be extended and the lower 
jaw held up by pressure against the chin to prevent closure of 
the epiglottis and interference with respiration. Several towels 
must be within easy reach, as vomiting is very apt to occur 
during the inhalation of the drug. 

Many forms of inhalers, some of them decidedly compli- 
cated, have been devised for the administration of ether, but 
in the emergency cases that may fall to the nurse an improvised 
" cone," made of folded newspaper covered with a towel or 
muslin, will usually be employed. The cone may be put together 
with safety-pins or needle and thread, and the towel or muslin 
should cover it inside as well as out. It should be of such a 
size that it will fit snugly over the patient's mouth and nose, 
and its depth should be from six to seven inches. A piece of 
absorbent cotton or a crumpled gauze about the size of a lemon 
is placed inside the cone and saturated with ether, care being 



ETHER. 



163 



taken that it is wedged securely in the inhaler with sufficient 
space between it and the patient's face to allow free vaporiza- 
tion of the drug. 

The cone is now placed over the patient's nose and mouth, 
but a short distance away from her face to avoid the choking 
sensation caused by the too sudden exhibition of the anaesthetic 
in its full strength. 

As soon as the woman's throat and lungs have become ac- 
customed to the irritating action of the vapor, the cone is to be 
brought gradually towards her face until it fits over it snugly. 

The gauze or cotton inside the cone should be kept saturated 
with the drug, and for this purpose about a drachm of ether 
must be poured in every two or three minutes. In doing this 
the bottle or can is to be uncorked and the cone removed for 
an instant only, as the fresh ether is added, and replaced imme- 
diately over the face. A very few inspirations of air will be 
enough to delay the action of the anaesthetic materially. 

After five or ten minutes, and often when the patient seems 
to be passing quietly into a state of unconsciousness, she may 
suddenly begin to struggle violently and use all her strength 
to tear the cone from her face and get off the table or out of 
bed. This is due to the primary exhilarating effect of the drug, 
and is a condition to be watched for in every case. The patient 
is partly anaesthetized, as will be evident from her incoherent 
speech and unnatural behavior, and she must be securely held 
by assistants and fresh ether given freely until she becomes 
quiet again. 

The essential point in controlling the struggles of a par- 
tially anaesthetized patient consists in keeping all her limbs ex- 
tended at full length so that she cannot get a " purchase" on 
anything. Her arms must be held straight out at her sides, so 
that she cannot bend her elbows, and sufficient downward press- 
ure must be exerted just above her knees to prevent her drawing 
up her legs. 

At about this time the patient will often begin to vomit, and 
at the first sign of retching her head is to be turned as far as 
possible to one side to allow the vomited matter to escape from 



164 



A NURSE'S HANDBOOK OF OBSTETRICS. 



her mouth and prevent its possible entrance into the larynx. 
As this is clone the lower jaw is to be drawn upward and for- 
ward as much as possible, and fresh ether must be administered 
freely, for the vomiting will stop as soon as the anaesthesia is 
complete. The mouth must be wiped out frequently with a 
towel, or with gauze or cotton in an ordinary sponge-holder, 
and care must be taken that the tongue is well forward and has 
not fallen back and occluded the throat. 




Fig. 61. — Administration of ether. Cone held snugly over face; chin raised upward and 
forward and pulse taken at facial artery. 



Complete anaesthesia will be attained in from ten to twenty 
minutes after beginning the administration of ether, and it is 
maintained by adding about a drachm of ether to the cone every 
four or five minutes. 

During ether narcosis the patient's face should be slightly 
flushed, but never pale or cyanotic ; her respiration deep, pos- 
sibly stertorous (snoring), but never irregular; and her pulse 
full, of good quality, fairly rapid, but never intermittent. 

The nurse should not only zi'atcJi the respiratory movements 



BIRTH OF THE CHILD. 165 

of the chest and abdomen, but make sure that respiration is 
properly carried on by noting that ether vapor actually escapes 
through the cone with each expiratory act. 

As the patient's wrist is not usually within the reach of the 
anaesthetist, the pulse may be taken at the facial artery as it 
passes under the edge of the lower jaw at about its middle ; at 
the temporal artery, just in front of the ear; or at the posterior 
temporal artery, directly above the ear at the margin of the 
hairy scalp (Fig. 61). When, however, there is any doubt as 
to the character of the pulse taken at these points, it should 
always be counted at the wrist as well. 

The danger-signals in ether anaesthesia are a pallid or cya- 
notic face, irregularity or shallowness of respiration, and irregu- 
larity or extreme rapidity of pulse. 

In the majority of cases in which the administration of ether 
will fall to the nurse the physician will first anaesthetize the 
patient himself, and whenever the nurse is in the slightest doubt 
as to the subsequent condition of the woman under operation, 
she should call upon the physician for assistance or advice with- 
out delay. 

As soon as the baby is born and the cord is tied and cut, 
the infant, wrapped in a warm blanket, is to be removed to 
a safe place, out of harm's way, and the nurse is to return 
at once to the assistance of the physician. Old grannies and 
so-called " monthly nurses" have an insane desire to drop every- 
thing and wash the baby the instant it is born, but the profes- 
sional nurse must be entirely above any such ridiculous idea, and 
not annoy the physician by fussing with the infant when her 
services are needed at the side of the patient. From time to 
time, as opportunities offer, she should glance at the child to 
make sure that it is breathing properly and that there is no 
bleeding from the cord, but if it is well wrapped up and in a 
warm place it needs no further attention until the placenta is 
delivered and the mother made entirely clean and comfortable. 

The after-birth is usually expelled in from fifteen to thirty 
minutes after the birth of the child, and the nurse must have 
ready for its reception a bowl or other clean vessel covered with 



166 A NURSE'S HANDBOOK OF OBSTETRICS. 

a warm bichloride towel (Fig. 62), in which it is to remain until 
it has been examined by the physician and he has given his 
consent to its destruction. The importance of this examination 
of the placenta lies in the fact that it enables the physician to 
know if any part of it or of the membranes has been left behind 
in the uterus. 

The nurse will usually be called upon from time to time to 
relieve the physician in holding the fundus (see Fig. 113), and 
while she is so occupied he will doubtless take advantage of 
the opportunity to inspect the infant for deformity or malforma- 
tion of any sort. 

Every moment that is not occupied with other matters is to 
be devoted to putting the room in order and making the patient 
clean and comfortable, so that the evidences of the labor may be 
gotten out of the way with as little delay as possible. 

Delivery by the Nurse. — In certain cases the nurse will find 
it necessary to manage the entire labor herself, either because 
of precipitate labor or through delay in securing the services of 
a physician. 

It is needless to say that such cases progress rapidly, and 
that almost before any careful preparations can be made the 
pains are recurring with such frequency and severity that the 
patient must be put to bed and given the undivided attention of 
the nurse. 

It seldom or never happens that the nurse and her patient 
are entirely alone, and usually the husband, some female relative 
or friend, or a servant can be called upon to get a basin of hot 
water, add one or two bichloride tablets or prepare some sort of 
an antiseptic solution, and place it on a chair or table by the side 
of the patient for the nurse's hands. The boric acid wipes for 
the infant's eyes and mouth can also be called for, and, as there 
is never any special hurry about tying and cutting the umbilical 
cord, there is usually time for the scissors and tape to be boiled 
in a shallow dish with just enough water to cover them. 

If the patient is fully dressed, as may be the case in precipi- 
tate labor, some one should take off her shoes and stockings and 
remove her clothing as rapidly as possible, but without any show 



DELIVERY BY THE NURSE. 167 

of excitement, by cutting or ripping it if necessary. She should 
then be helped into a night-gown or, if this cannot be done, cov- 
ered with clean sheets and blankets ; and a pad or thickly folded 
sheet should be slipped under her buttocks in an effort to protect 
the bedding and carpet from blood and other discharges. 

All these matters may be attended to by the direction of the 
nurse as she sits or stands by the patient's side and watches 
carefully the progress of the case, and if she keeps her wits about 
her and does not lose her head she will have no difficulty in 
securing an immediate mastery of the entire situation. 

As soon as the basin of antiseptic solution is prepared the 
nurse should wash her hands in it as thoroughly as possible and, 
with cotton sponges, clean the external genitals carefully, while 
clean towels placed under the buttocks and about the thighs will 
do much to prevent the possibility of infection. 

Whenever there is time for her to do so, the nurse should, of 
course, disinfect her hands with the utmost thoroughness, roll up 
her sleeves, or take them off if they are made in such a way that 
this is possible, and put on an operating-gown if she has one. 
The hands are to be disinfected by scrubbing for fine min- 
utes with Tincture of green soap and hot water, changing 
the water frequently, and then soaking for three minutes 
in bichloride solution (1 to 2000). The room, the bed, and 
the patient are all to be prepared for the labor as carefully 
as the time will allow, and in those cases in which the nurse is 
called upon to conduct the delivery merely because of prolonged 
delay in the arrival of the physician she will, of course, have 
everything in complete readiness. 

As the head comes down and begins to distend the perineum 
the nurse must watch it carefully, and prevent undue stretching 
of the parts by holding it back at the acme of each pain (Fig. 
63). This interference with the descent of the head to prevent 
its sudden expulsion through the vulva and consequent lacera- 
tion of the tissues may be kept up for fifteen minutes or more, 
or until the parts are stretched to their utmost capacity and the 
head escapes in spite of every effort to hold it. The essential 
points are to delay the descent of the head until complete dila- 



1 68 A NURSE'S HANDBOOK OF OBSTETRICS. 

tation has taken place and to prevent its sudden delivery if 
possible. 

If the membranes have not ruptured, they may, when the case 
is under the management of the nurse, be left intact until they 
appear at the vulva, resembling more than anything else in 
appearance the rounded end of a large bologna sausage. As 
soon as they protrude in this way and the nurse has convinced 
herself by careful examination that the presenting object is the 
amniotic sac filled with fluid, and not any part of the foetus 
itself, the patient is to be informed of the nature and harmless- 
ness of the discharge of waters which is about to occur, and the 
sac is to be ruptured. This may be done easily and quickly by 
cutting through the tissue with the finger-nail at the height of a 
pain after a towel has been placed against the vulva to receive 
the gush of waters. 

As soon as the head is bom the nurse should feel about the 
neck for the umbilical cord, and, if it is found, it should be 
drawn gently to one side or the other until it can be slipped over 
the head. No force should be used in loosening the cord, for 
fear of injuring it and causing bleeding. 

The mouth and eyes of the infant are now to be carefully 
cleaned with the boric acid solution, and the face must be held 
up so that it does not lie in the pool of blood and liquor amnii 
between the mother's thighs. 

There is no occasion whatever for haste in the delivery of 
the body, even if the face of the infant becomes distinctly cya- 
notic, and the mother and others in the room may be assured' 
that everything is satisfactory and that there is no danger or 
cause for alarm. In another moment the uterus will again con- 
tract and the body of the child will be expelled. 

If only the shoulders appear there is no harm in passing a 
finger, which has been carefully rinsed in the antiseptic solution, 
into the axilla and gently extracting the posterior arm. The 
body will now almost fall out of the vagina, and the infant is to 
be laid on its right side, between the mother's legs, and covered 
with a warm woollen cloth or the nearest substitute for this 
which can be secured. 




Fig. 63. — Holding back the head to prevent sudden expulsion and the consequent 
laceration of the maternal tissues. 



FIRST RESPIRATION. 



169 



If the child does not cry vigorously it may be spanked ener- 
getically but without too much force, or held up by its heels and 
slapped sharply on the back four or five times (Fig. 64). If 
this is not successful, a little ice-water may be splashed briskly 



:' : ' 


1 

\\ 1 




' \ 


[__ 





fie. 64.— Infant suspended by heels. Nurse slapping its back immediately after birth to 
excite respiratory movements. Umbilical cord clearly shown. 

on its chest, but usually the slapping will suffice. In holding 
the baby up by its heels care must be taken that no traction is 
allowed to come on the umbilical cord. 

The instant the child is born the nurse, or one of those pres- 
ent in the room, must place a hand on the patient's abdomen and 
grasp the fundus firmly (see Fig. 113), and this pressure is to 
be maintained without interruption for the next full hour. As 
this is a very tiresome procedure, it is well for those having the 
matter in hand to relieve each other at fairly frequent intervals. 
The correct way to hold the fundus is described in detail in 
Chapter XIX. 

There need be no hurry about tying the umbilical cord, and 
the nurse may safely wait until the pulsations in it have ceased 
or grown very faint. The first ligature is to be placed about 
three inches from the infant's abdomen, to leave room for subse- 



i;o A NURSE'S HANDBOOK OF OBSTETRICS. 

quent tying in case of hemorrhage, and the second ligature two 
or three inches from the first. It is a good plan to tie a third 
tape around the cord, close to the vulva, to serve as a guide to 
the descent of the placenta. As the after-birth is forced out of 
the uterus the cord will also escape from the vagina, and the 
progress of this expulsion can be estimated by watching this 
third ligature, which at the beginning was as close to the vulva 
as possible. 





Fig. 65. — Square knot. 

The ligature should be tied with a " square knot " (Fig. 65), 
for the ordinary, or so-called " Granny " knot, will almost surely 
slip, after a short time, no matter how tightly it may have been 
drawn when it was applied. The characteristic feature of the 
" square knot " lies in the fact that both ends pass under the 
same side of the loop, as shown in the figure, while in the 
" Granny knot " one end passes under and one over. If hemor- 
rhage occurs from the cord after it has been tied and the child 
dies or even is seriously weakened by loss of blood great blame 
will attach to the nurse, and it will be an extremely difficult mat- 
ter for her to free herself from the stigma of either neglect or 
incompetency. 

Consequently, the nurse who intends to practise obstetrics 
should make it a point to perfect herself in the method of tying 
a square knot until she can do so instinctively, and so avoid the 
possibility of any such accident as has been suggested. It will 
avail her nothing that the case was an emergency one and that 
she did her best under most trying and unusual conditions, for 
people who are desirous of having children allow nothing to 
escape the fury of their wrath if anything untoward occurs in 
the conduct of the case, and the fully trained nurse of to-day is 
regarded by many as the equal of the physician in technical skill. 

Be this as it may, it is a very easy matter to learn to tie the 
square knot snugly and securely, and when this is done properly 



TYIXG THE CORD. 



171 



there will be no clanger of its slipping or of secondary hemor- 
rhage from the cord, except in the case of feeble or premature 
children, in whom the tendency to bleeding is very great and who 
must always be watched with the utmost care. As many of the 
precipitate labors which will fall to the care of the nurse will be 
cases of premature birth, she must be extremely careful about 
tying the cord securely, and inspect it for hemorrhage at frequent 
intervals, tying it a second, or even a third, time if necessary. 

The cord must alzeays be tied in two places and cut between 
the ligatures, for if tJiis is not done and the case should chance 
to be one of tzvins, the unborn child might possibly bleed to death 
from the maternal end of the severed cord. 




Fig. 66. — Granny Knot. 

As soon as the cord is cut the infant, wrapped in a blanket, 
is to be removed to a safe place, and the nurse should take charge 
of the fundus for a few minutes, at least, to make sure that it 
is hard and firm. If it is found to be soft and flabby vigorous 
kneading of the abdomen should be practised until the uterus 
again contracts properly. 

There need not be the slightest haste about the delivery of the 
placenta, and while it is usually expelled in from fifteen to thirty 
minutes after the birth of the child, no harm will result if it is 
delayed for an hour or more, provided there is no excessive 
bleeding. It is to be remembered that the uterus is resting during 
this period, and that when its muscular fibres have recovered 
from the exhaustion of the labor they will contract firmly and 
expel the after-birth. Under no circumstances should traction 
be made on the cord in an effort to pull the placenta out of the 
vagina, for this will probably result merely in tearing the cord 
from its attachment, while in rare cases, when the placenta has 
not entirely separated from the uterine wall, the womb itself may 
be dragged inside out, causing the condition known as inversion 
of the uterus (see Fig. 105). 



172 



A NURSE'S HANDBOOK OF OBSTETRICS. 



In nearly every case, after a reasonable period of time, the 
woman will have another labor-pain and the placenta will appear 
at the vulva, much like a miniature counterpart of the fetal head. 
It should be received in the palm of the hand and directed into a 
bowl held for this purpose, and the string of membranes that 
trails behind is to be extracted with the utmost gentleness and 
deliberation, to prevent the detachment of any tags or fragments 
(Fig. 6y). The method, formerly advised, of twisting the mem- 





X _ - / 



1 




Fig. 67. — Delivery of placenta and membranes. (Bumm.) No traction should be used, but 
the membranes allowed to fall out of the vagina by their own weight. 

branes into a firm cord by turning the placenta over and over on 
itself no longer meets with general approval and is not to be 
recommended. All that is necessary is to extract the membranes 
from the vagina slowly and carefully, taking plenty of time and 
using no force whatever. 

The placenta is to be preserved until the arrival of the physi- 
cian, in order that he may inspect it and make sure that it is 
intact. 

In precipitate breech cases, which occur when the infant 
is small or premature, there are two important points in trie 
management which the nurse must not forget. 

Traction on the body, after it has passed through the vulva, 



BREECH CASES. 



173 



must never be made, for it is essential to have the case progress 
as slowly as possible in order to secure complete dilatation of the 
parts and afford ample room for the passage of the head. 

Pressure must be made on the fundus as soon as the nature 
of the case is recognized, and maintained until the child is born, 
111 order to prevent, if possible, the extension of the arms above 
the head. 




J% 



f 3f? 



Fig. 6S. — Delivery of the head in breech cases. The child's body is lifted up and back- 
ward over the mother's abdomen, and the head is pressed forward, so that the chin, mouth, 
nose, etc., will be successively delivered. 



The diagnosis of a breech presentation can often be made 
by the nurse, without vaginal examination and before the ap- 
pearance of the infant's buttocks at the vulva, by the escape of 
meconium in the vaginal discharge. 

As soon as the body is delivered to the level of the umbilicus 
the cord is to be secured and gently drawn clown a few inches, 
to prevent traction on it when the head is born, and the extruded 



174 A NURSE'S HANDBOOK OF OBSTETRICS. 

portion of the foetus is to be wrapped in warm towels, which are 
to be renewed as often as they become cool. This is necessary, 
not only to prevent chilling the infant, but to avert the danger 
of respiratory movements while the head is still undelivered, due 
to the shock of cold air striking the abdomen and chest. 

The downward pressure on the fundus in the direction of the 
axis of the pelvic brim is to be kept up, and, when the shoulders 
have escaped from the vulva, the arm which is the more easily 
reached is drawn out of the vagina by passing a finger over the 
infant's shoulder, down the arm to the elbow, and sweeping the 
forearm and hand across the face and chest into the world. The 
other arm is delivered in the same way, and then the body of 
the infant is raised upward and backward until it almost lies on 
the abdomen of the mother (Fig. 68) to favor the birth of the 
head. 

Unless the head can be delivered within five minutes after it 
has passed into the cavity of the pelvis the life of the child will 
be in great danger from pressure on the cord, and if there is 
any delay the nurse may pass one or two fingers into the child's 
mouth, and with those of the other hand under the symphysis 
pressing on the occiput, attempt to tip the head forward on the 
chest while the body of the infant is raised upward and backward 
and firm downward pressure is made by an assistant through 
the abdominal wall. • 

Fortunately the cases of breech delivery that will fall to the 
care of the nurse are seldom attended with any great difficulties, 
for the very fact of their precipitate character presupposes a 
small child or a very large pelvis. The chief danger is extension 
of the arms above the head (Fig. 69), and this can often be 
avoided by the maintenance of firm pressure on the abdomen 
throughout the entire course of the labor. 

After the child is delivered the further management of the 
'case does not differ from that of vertex presentation. 

Twins are not infrequently delivered precipitately on account 
of the small size of each infant, and unless they are " locked" in 
such a way that neither can be expelled without artificial aid 
(Fig. 70), twin births seldom or never give any trouble to the 



PRECIPITATE LABOR. 175 

medical attendant. As the babies are small, the first is delivered 
with very little difficulty, and the birth of the second is accom- 
plished with the utmost ease, because the passages are already 
dilated fully and there is nothing to interfere with its descent. 




Fig. 69.— Arms extended in breech delivery. The most serious complication that can arise 
in the extraction of the after-coming head. 

None of the other abnormalities of position and presentation 
possesses any special interest to the nurse, for, unless they are 
of such a precipitate character that delivery is accomplished 
within a very short time, there will be ample opportunity to 
secure the services of some physician, even if the regular medical 
attendant cannot be reached. 

When the nurse finds, on her arrival, that the baby and pos- 
sibly the- placenta are born and lying in the bed, her first duty is 
to grasp the fundus with as little delay as possible and see if its 
contraction is satisfactory, and then make sure that the child is 
not lying face downward in the blood and discharges and in 
danger of strangling. As soon as the fundus is firm and solid 



176 A NURSE'S HANDBOOK OF OBSTETRICS. 

the cord may be tied and cut and the infant turned over to some 
one who will wash its eyes and mouth and wrap it in a warm 
blanket. 




Fig. 70. — Locked twins. (R. Barnes.) First child partly born in breech presentation, the 
second lodged with the face under the chin of the first. 

In all cases of labor occurring in the absence of the physician 
the nurse must keep a cool head, for the patient and those about 
her are usually in a state of great excitement and turmoil, and 
this may be enough to cause relaxation of the uterus and trouble- 
some hemorrhage. 

A level-headed nurse, who shows no trace of nervousness or 
fear, can often change the entire picture in an instant and bring 
order and quiet out of chaos with a word and an air of authority 
and self-confidence. 



XVI 

Operative Delivery 

Operative delivery may be either instrumental or non- 
instrumental. 

Instrumental delivery may be further divided into three 
classes, — cutting operations, non-cutting operations, and muti- 
lation of the feet us. 

The non-instrumental form of delivery consists in turning 
the fcetus with the hands from an undesirable into a desirable 
position in the uterus. This operation is termed version, and 
may be performed in any one of three ways, — by external ma- 
nipulation through the abdominal wall alone, called " external 




.} 



Fig. 71.— Internal version. (Garrigues.) Entire hand in the uterus grasping a foot 
As the foot is drawn down the protruding arm will be drawn up into the womb, and the 
child will be delivered by the breech. 



version;" by internal manipulation through the vagina alone, 
called "internal version" (Fig. 71) ; and by a combination 
of these two methods, in which one hand is placed on the abdo- 
men of the mother and the other in the vagina with the finger- 

12 177 



178 A NURSE'S HANDBOOK OF OBSTETRICS. 

tips in the uterus, called " combined version" or the " Brax- 
ton-Hicks Method" (Fig. 72). 




Fig. 72.— Combined or bipolar version. (Garrigues.) The finger in the vagina is assisted 
by the other hand on the abdominal wall. 

External version can only be performed before labor has 
begun, or immediately after and before the membranes have 
ruptured. It is often employed to convert a breech or trans- 
verse presentation into that of the vertex when the abnormality 
is recognized at a sufficiently early date to admit of the neces- 
sary manipulation. 

The combined, bipolar, or Braxton-Hicks method has a 
not much wider field of usefulness than the external method, 
and must also be done before or very early in labor. The finger- 
tips in the uterus push the undesired presenting part to one side, 
while the other hand of the operator presses through the abdom- 
inal wall and forces the desired fetal pole into the pelvis. The 
operation requires considerable skill and great patience and 
perseverance, and really amounts to turning the fcetus around 
in the uterus and passing it along in a gradual, jerky way over 
the finger-tips until it is in a proper position. 

Neither external nor combined version call for the admin- 



VERSION. 



179 



istration of an anaesthetic unless the patient is in an extremely 
nervous condition or her abdominal wall is rigid and unyielding. 
The operation is not at all painful, but is often unsuccessful, 
either because it proves to be entirely impossible, or, as is more 
often the case, because the foetus returns to its original position 
within a few hours. 

The patient is to lie on her back, with her knees drawn up 
enough to relax the abdomen, and as soon as the fetal position 
has been corrected a firm binder should be applied with long 
pads on each side of the belly to prevent any change of position. 




Fig. 73.— Lithotomy position. Limbs supported in author's leg-holder and field of opera- 
tion surrounded with sterile towels. 



In these two forms of version the head of the foetus is almost 
invariably the part that is brought into the 'pelvis, and frequently, 
as soon as this is accomplished, the physician will rupture the 
membranes artificially and allow T labor to proceed at once. 



180 A NURSE'S HANDBOOK OF OBSTETRICS. 

When internal version is performed the entire hand is 
introduced into the uterus, and instead of the head, as in the 
external and combined methods, a foot is grasped and brought 
down into the vagina, or even out of the vulva, converting the 
case into one of breech delivery (see Fig. 71). 

The patient is to be placed on her back in the lithotomy 
position, with her legs elevated and held by assistants or sup- 
ported in a leg-holder (Fig. 73). Anaesthesia is always neces- 
sary, and should be carried to the degree of complete uncon- 
sciousness. The os uteri must he dilated sufficiently to admit 
the closed fist of the operator before the operation is begun, or 
rupture of the uterus may result; the membranes must, of 
course, be ruptured, in order that the surgeon may grasp a 
foot, and the bladder must always be empty. 

While external and combined version carry no danger what- 
ever to either mother or child except, in the latter variety, 
through possible infection of the uterus by a surgically unclean 
operator, internal version is extremely dangerous to the infant, 
and to the mother is one of the most perilous operations of sur- 
gery, not excepting those which necessitate opening the abdomi- 
nal cavity. 

Of the non-cutting instrumental operations, the most com- 
mon is FORCEPS DELIVERY. 

Forceps are merely metal substitutes for hands, which can 
grasp the sides of the fetal head, or rarely the breech, and draw 
it down and out of the pelvis (Fig. 74). 

Forceps operations are divided into three classes, — high, 
medium, and low. The high operation is done when the head 
is at or above the pelvic brim. It is extremely dangerous to 
the mother on account of the possibility of rupture of the uterus, 
and may be even more serious than version. The medium 
operation is done when the head has passed through the brim 
but lies in the vagina and does not yet distend the perineum. 
The low operation is done when the head lies well down on 
the perineum and pushes forward the vulva so that it is, in 
many cases, in plain sight. 

In all forms of forceps deliveries the os uteri must be fully 



FORCEPS OPERATIONS. 



181 



\w\ 




Fig. 74.— Forceps applied to head of brim. (Garrigues.) 




Fig. 75.— Walcher posture. This position tilts 1 lie pelvis forward and increases the true 
conjugate diameter nearly half an inch. 



182 



A NURSE'S HANDBOOK OF OESTETRIC5. 



dilated, the membranes ruptured, and the bladder empty before 
the instruments are applied. 

The patient lies in the lithotomy position on a bed or table, 
with her buttocks drawn well over the edge. and. except in the 
case of a low operation, complete anaesthesia is required. If 
an anaesthetic is not used the patient may struggle and injure 
herself severely with the instruments. 

In certain rare cases where difficulty* is encountered in making 
the head enter or " engage in" the pelvic brim, the physician 
will wish the patient placed in the JJ'alcher posture (Fig. 75 . 
This consists in lowering the legs until they hang freely over 
the edge of the table, while the buttc :i:s are raised by means 
of a thick pillow or a folded blanket. This tilts the pelvis for- 
ward, so that there is an increase of nearly half an inch (one 
centimetre) in the true conjugate diameter of the inlet; but to 
be effective, the position of the woman must be such that she 
is just at the point of slipping off the table, — an accident to be 
guarded against by suitable support from assistants at her 
shoulders and hips. 

The most common types :: ::r:e;s are the " Elliot: rig. 
7: and " Simpson*' 1 Fig. jj) patterns, with fenestrated blades. 




Fig. 76. — Elliott's forceps. 



the " Tucker-McLane" instrument 'Fig. yS) . with solid blades, 
and the "axis-traction" forceps (Fig. 79), which is only used 
for performing the high operation. With the axis-traction 
instrument the handles are used merely for applying the blades, 
and all the traction force is exerted on a handle-bar. which is 
attached, after the instrument is in place, to rods fastened to 
the lower part of the blades. It is an extremely powerful instru- 



FORCEPS. 



183 




Fig. 77. — Simpson's forceps 




Fig. 78. — Tucker-McLane forceps. 




Fig. 79. — Tarnier axis-traction forceps. 



184 A NURSE'S HANDBOOK OF OBSTETRICS. 

ment, and a very dangerous one in the hands of an operator 
unaccustomed to its use. 

Forceps, like other instruments, should be boiled before use, 
and the nurse should have ready sterile vaseline or other suita- 
ble lubricant for anointing them and the hands of the operator. 

The indications for the performance of version or the use 
of forceps do not especially concern the nurse, but in general 
it may be said that external and combined version are performed 
as prophylactic measures to correct a malposition before or 
early in labor; internal version is done when, for any reason, 
speedy delivery is necessary, as in cases of eclampsia or of 
hemorrhage; low and medium forceps are chiefly indicated in 
cases of uterine inertia, when the patient is exhausted after pro- 
longed expulsive efforts ; and high forceps are used usually on 
account of pelvic contraction or overgrowth of the foetus. These 
statements are, of course, made in a very general way, and must 
not be regarded in any other light, for the subject is a very 
complex one and cannot be treated briefly. 

Often, before performing version or using forceps, the sur- 
geon finds it necessary to dilate the cervix artificially. He may 
do this with his fingers or hands, or he may use rubber bags 
distended with water. These bags are of two kinds, — the 
"Barnes" bag (Fig. 80), which is fiddle-shaped, and the 
" Champetier de Ribes" bag (Fig. 81), which is conical. Both 
varieties come in sets of different sizes, and the largest one that 
can be inserted is passed into the cervix and slowly distended 
with water pumped in through a Davidson syringe (Fig. 82). 
The water should be warm (no F.), and must invariably be 
sterilized by boiling, so that if a bag bursts the accident will 
cause no danger of infection. The bags themselves should, 
of course, be boiled to sterilize them inside and out, and before 
this is done the nurse should test each bag by pumping it full 
of water to make sure that it does not leak. 

The bag, whether of the Barnes or Champetier de Ribes 
pattern, is passed into the cervix by means of a specially con- 
structed instrument or with an ordinary sponge-holder. In 
private practice the nurse will often be called upon to hand the 



DILATATION OF THE CERVIX. 



185 





Fig. So. — Barnes's bags. For rapid dilatation of the cervix. 




Fig. 81.— Champetier de Ribes bag. For dilatation of the cervix. 




Fig. 82 — Bulb and valve, or " Davidson" syringe. 



1 86 A NURSE'S HANDBOOK OF OBSTETRICS. 

bag, grasped in the forceps, to the surgeon for introduction, 
and it should be rolled or folded as compactly as possible and 
secured between the blades of the instrument, as shown in 
Fig. 83. 




Fig. 83. — Bag in grip of forceps. 



The most important of the cutting operatioxs on the 
mother is that by which the child is extracted through an in- 
cision in the abdominal wall and uterus. This operation is called 
" Cesarean section," the name being supposed by some au- 
thorities to have reference to the alleged fact that Julius Caesar 
was born in this manner, while others maintain that the word is 
derived from the Latin cccsus, from cccdere, to cut. 

Cesarean section may be performed in one of two ways, 
— the entire uterus and its appendages may be removed, or the 
uterus may merely be incised, the infant and placenta extracted, 
and the wound closed with catgut sutures, after which the 
abdominal incision is closed in the ordinary way. 

Formerly, when the Cesarean operation was one of the most 
dangerous in surgery, it was customary to remove the uterus, 
.ovaries, and tubes, if for no other reason than to prevent the 
'possibility of a subsequent pregnancy, but at the present time 
there is so little danger attached to this form of delivery that 
most operators prefer to leave the uterus, unless it is itself the 
seat of disease. 

Cesarean section is not to be regarded as an emergency 
operation. That is to say, it should not be performed without 
due preparation, and never, if it can be avoided, when the pa- 
tient is exhausted after protracted labor and futile attempts at 
delivery by forceps or version. Under such circumstances it 



CESAREAN SECTION. 



187 



is very apt to result fatally to the mother either from shock or 
infection or both, while, if it is performed by a competent sur- 
geon either just before or immediately after the natural onset of 
labor, with the patient in good condition and all necessary con- 
veniences and assistants at hand, it is almost universally success- 
ful. Consequently, it is easy to understand that the best results 
in Caesarean section will follow careful and thorough ante- 
partum examination, by which the surgeon may know in ample 
time that the patient cannot by any possibility be delivered of 
a living child through the natural passages at full term or at 
any period of pregnancy sufficiently advanced to permit of its 
living. It is hardly necessary to say that the operation subjects 
the child to no danger whatever, and that if it is in good con- 
dition at the time when the abdomen is opened it will be de- 
livered successfully. 




Fig. 84.— Pelvic tumor preventing delivery. (Garrigues.) Large ovarian cyst, in front of 
head, obstructing the genital canal. 

The chief indication for Caesarean section is contraction or 
deformity of the pelvis which is so marked that it is impossible 
for a viable child to pass through it even with the assistance 
of forceps or version, and it may also be rendered necessary 
by the presence of abdominal tumors (Fig. 84), cancer of the 
cervix, overgrowth of the fcetus, monstrosity, certain cases of 



i88 



A NURSE'S HANDBOOK OF OBSTETRICS. 



twins, and certain malpositions of the foetus which cannot be 
corrected. 

In malignant disease (cancer) of the cervix the uterus and 
appendages are usually removed at the time of the operation, 
unless the mother is already in a hopeless condition and the 
section is performed solely in the interest of the child. 

As in any other abdominal operation, the patient lies on her 
back on a firm table, with a Kelly pad under her buttocks (Fig. 
85). All the hair on the abdomen, mons veneris, vulva, and peri- 




FiG. 85. — Kelly pad in position under patient, with apron draining into tub or pail. 



neum is to be carefully shaved off, and the belly, external genitals, 
and thighs scrubbed and disinfected with the utmost care. The 
vagina is also usually made as sterile as possible, but this is 
generally performed by the surgeon or his assistant, and need 
not be taken up by the nurse, except under definite instructions. 
The case calls for at least two nurses, and four assistants to 
the operator. The head nurse has direct charge of the solutions, 
irrigation, and dressings, and the second nurse makes herself 
generally useful. The operator stands at the right side of the 
patient, facing her head; opposite him is the first assistant, 
facing the patient's feet. Standing on the same side of the 
patient as the first assistant, and facing him, is the second assist- 
ant, whose duty is usually to grasp the blood-vessels at the 



CESAREAN SECTION. 189 

cervix after the abdomen is opened and control hemorrhage as 
much as possible when the uterus is incised. The third assist- 
ant gives the anaesthetic, and the fourth stands behind the oper- 
ator, out of the way, ready to take charge of the baby the instant 
it is extracted. The head nurse stands between the first and 
second assistants, facing the operator, but at a sufficient distance 
from the patient to be out of the way, and at her side should be 
a table with flasks (Fig. 86) or pitchers of saline solution (six- 





Fig. 86. — Sterile salt solution in flasks. 



P'ig. 87. — Sponge made of cotton and gauze. 



tenths per cent.) at a temperature of 118 F. and plenty of hot 
sterile water, cotton sponges (Fig. 87) in holders (Fig. 88), 




Sponge-holder. 



intestinal pads (Fig. 89), and iodoform gauze strips (five per 
cent,) in tubes (Fig. 90) for packing the interior of the womb 
before the uterine wound is closed. The pads, for holding back 
the intestines as the uterus contracts, must be supplied with 
long tapes and carefully counted and recorded before the be- 
ginning of the operation. From time to time the head nurse 
will be called upon to pour hot salt solution over the uterus to 



KjO A NURSE'S HANDBOOK OF OBSTETRICS. 

stimulate contractions, and she must be ready with this at a 
proper temperature (n8° F.) at a moment's notice. 

The second nurse must keep a close watch on her superiors, 
so that she can obey a glance instantly. 




Fig. 89.— Intestinal pad of folded gauze. Usual size about eight by ten inches. The 
tape extends out of the wound during the operation to avoid the possibility of leaving a 
pad bebind when the abdomen is closed. 

The anaesthetist is to be provided with a small table for his 
hypodermic syringe, tongue-forceps, throat-swabs, and stimu- 
lants, and the surgeon's instruments are laid out (usually by 
himself in definite arrangement) on a table close by his side 




Fig. 90. — Gauze packing:. 

where he can reach them easily. Some surgeons prefer a fifth 
assistant to pass instruments, but as this plan increases the dan- 
ger of infection by bringing another (and unnecessary) pair of 
hands into the case, it is gradually being abandoned. 

The essential things for the nurse to have ready in private- 
practice are: 



CESAREAN SECTION. 



I 9 I 



Protection for the carpet, unless it is removed altogether, 
for blood and solutions readily escape to the floor. 

A firm table for operating, narrow and long. Usually two 
kitchen tables, placed end to end, answer perfectly. These 
should be covered with a clean blanket, rubber sheeting, and 
sterile white sheet, all pinned securely in place. 

A table for instruments at the right side of the patient, with 
space between it and the operating-table for the surgeon to 
stand. This, of course, is to be covered with sterile towels or 
sheet. 

A table for dressings, packing, solutions, etc., on the left 
side of the patient, about four feet away, also covered with sterile 
or bichloride towels. 

A small table at the patient's head for the anaesthetist. 

Two clean slop- jars or pails, one on either side of the oper- 
ating-table, for receiving soiled towels and sponges and as much 
of the blood and solutions as can be directed into them. 

Two dozen sterile towels. 

Five gallons sterile salt solution, with enough boiling water 
to raise it instantly to any desired temperature. 

Three dozen large sterilized safety-pins. 

Pitchers or flasks for pouring salt solution. These must be 
sterilized and wrapped in sterile or bichloride towels. 

Hot and cold water in large pans, and ice, all in a distant 
part of the room, for resuscitating the baby. 

A warm bed for the baby. 

A warm bed for the mother, with plenty of hot-water bot- 
tles, and provision for raising its foot in case of shock. In 
emergencies the best hot-water bottles are beer-bottles with pat- 
ent stoppers, which can be corked rapidly and securely. 

Bichloride tablets. 

Tincture of green soap or " synol soap," eight ounces. 

Four nail-brushes. 

Four wash-bowls of good size for hand cleaning. 

Two or three extra wash-bowls for solutions. 

Hot and cold sterile water for scrubbing the hands. 

A warm room (75 to 8o° F.) 



192 A NURSE'S HANDBOOK OF OBSTETRICS. 

A good overhead light. 

The surgeon should bring all neccessary instruments, pads, 
gauze packing, and dressings, and may be expected to do so 
unless he expressly instructs the nurse to provide them. 

Symphyseotomy is an operation once in high favor among 
certain operators, but now, in view of the almost uniform suc- 
cess of properly timed and skilfully performed Cesarean sec- 
tion, gradually passing into disuse. It consists in cutting through 
the cartilage lying between the ends of the two pubic bones at 
the symphysis pubis and allowing these bones to separate for a 
distance of about one and one-half inches, so as to make greater 
space for the passage of the head. The chief objection to the 
operation is that after this separation has occurred it is not at 
all certain that enough room will have been gained to permit 
delivery, and it may, after all, have to be completed with for- 
ceps or by version. Moreover, in some few cases the bones have 
failed to unite after the operation, and the patient has been 
unable to walk. 

The woman is placed in the lithotomy position, and the legs 
are not supported in leg-holders, but are held by two trained 
assistants whose duty it is to regulate the amount of separation 
in the joint. 




Fig. 91. — Galbiati knife. For cutting through the symphysis pubis in symphyseotomy 

After the bladder has been emptied and the urethra drawn 
out of the way by means of a male sound passed into the canal, 
an incision is made directly over the symphysis pubis and a 
curved knife, known as the "Galbiati knife" (Fig. 91), is 
hooked under the symphysis and drawn up through the joint 
until the parts are separated. A little gauze is then packed 
into the wound to prevent oozing, and while the assistants hold- 



SYMPHYSEOTOMY. 193 

ing the legs keep them in such a position that the separation will 
not exceed one and one-half inches, the labor is allowed to pro- 
ceed if it will, or is terminated by forceps or version if neces- 
sary. 

One nurse is all that is needed, and the surgeon requires 
three assistants, — one to give the anaesthetic and two to hold the 
legs. The dressings should be provided by the surgeon, and 
consist of iodoform gauze to pack the wound, cotton, plain 
gauze, adhesive plaster strips, and a special binder or a many- 
tailed bandage. 

Certain operators join the bones with silver wire, but this is 
seldom done now, as it is found that firm coaptation of the parts 
by pressure, with the adhesive plaster drawn tightly around the 
body, will give equally good results. 

The after-care of these cases is very important and very diffi- 
cult, for under no circumstances can the thighs be separated 
until union is complete in the joint, and, as this occupies a period 
of about six weeks, it is extremely trying to the patient and 
troublesome for the nurse. Dr. Edward A. Ayres, of New 
York, has devised a " symphyseotomy bed," which is a sort of 
canvas hammock swung from a high frame and so arranged that 
a strip can be removed from the bottom and the buttocks un- 
covered when it is necessary to move the bowels or empty the 
bladder. In other cases the patient lies flat on a hard bed, with 
long sand-bags at each side of the hips, and when the catheter 
is used the legs, tightly bound together, are raised straight up 
in the air until the thighs are at right angles to the body and 
the catheter is inserted from below. While but one nurse is 
actually needed for the operation of symphyseotomy, at least 
two and often three are required to give the patient the proper 
after-treatment. 

Episiotomy is an operation designed to substitute for an 
unavoidable, ragged, central laceration of the perineum a clean 
incision, made with a knife, at each side of the vaginal floor. 
The only instruments required are a scalpel (Fig. 92) and suture 
material, with needles and needle-holder (Fig. 93) for imme- 
diate repair after delivery has been effected. No assistants or 

13 



194 



A NURSE'S HANDBOOK OF OBSTETRICS. 



special nurse are needed. The operation often causes trouble- 
some hemorrhage, and is seldom if ever performed at the present 
time. 




Fig. 92. — Scalpels. 




Fig. 93. — Needle-holder. 



The mutilating operations on the foetus are termed 
" embryotomy," and are divided into craniotomy, which con- 
sists in crushing the fetal head; decapitation, or amputation 
of the head ; and evisceration, or removal of the thoracic and 
abdominal contents, piece by piece. When evisceration is per- 
formed it is usually necessary to follow it by craniotomy, for 
any condition which will not permit the passage of the chest or 
abdomen will almost certainly interfere to an even greater de- 
gree with the delivery of the head. 

Embryotomy in any of its forms is a rare operation, and 
one that should seldom be necessary if the patient has been 
under careful supervision throughout the course of her preg- 
nancy. Its indications are, in general, the same as for Csesarean 
section, but it is not justifiable unless the child is dead or 
the mother too much exhausted to withstand the shock of 
the abdominal operation. This procedure is, of course, neces- 



CRANIOTOMY AND DECAPITATION. 195 

sarilv fatal to the child, but the dangers to the mother from the 
operation itself are very few indeed, the great difficulty in such 
cases being that it is usually delayed until the woman is in a 
critical condition, either from exhaustion or from attempts at 
other methods of instrumental delivery. 

Embryotomy is a most unpleasant operation to witness or 
perform, but it is not, as a rule, painful, and an anaesthetic is 
required only to spare the mother the distressing spectacle of 
the mutilation of her infant. 

In almost every case the child is dead when the operation 
is begun, but it must be remembered that it is sometimes justi- 
fiable, in the case of a living child, to save the mother or to save 
one twin (as in cases of locked heads), when otherwise both 
children and possibly the mother herself would be lost. The 
nurse may be consulted by the family in these extremely rare 
cases as to the propriety of performing the operation on the 
living child, and she must not permit sentimental feelings to 
close her eyes to the fact that the mother is of far more impor- 
tance than the unborn child, and that when it is necessary to 
sacrifice the child in order to save the mother the latter should 
always receive the first consideration. It does not take a great 
deal of moral courage to arrive at this conclusion when it is 
remembered that in these cases delay will usually result in the 
loss of both lives, while prompt operation and the sacrifice of 
one may, and probably will, be the means of saving the other. 

Craniotomy is performed by perforating the fetal skull to 
allow escape of brain tissue and then crushing the head into 
as compact a mass as possible for extraction. The usual instru- 
ments for this purpose are the perforator and cranioclast (Figs. 
94 and 95), but the best and most modern appliance is the basio- 
tribe (Fig. 96), which resembles somewhat an obstetrical for- 
ceps, and which combines in one instrument the perforator, 
crusher, and extractor. 

Decapitation is seldom necessary except in the case of 
locked twins (see Fig. 70), when the body of the first infant is 
removed after decapitation, the head pushed out of the way while 
the second child is extracted, and last of all the severed head 



196 



A NURSE'S HANDBOOK OF OBSTETRICS. 



removed with forceps. The operation may also be necessary in 
impacted shoulder presentations (Fig. 97), where the body is 
firmly wedged in the pelvis and cannot be pushed up above the 
brim. 




Fig. 94.— Naegele's perforator. 




Fig. 95. — Braun's cranioclast. 




Fig. 96. — Tarnier's basiotribe. 



The only special instrument used for decapitation is the 
" Braun's hook" (Fig. 98), which may either be blunt or sharp- 
ened to a knife edge at the concavity of its crook. 



EVISCERATION. 197 

Either hook is to be passed over the neck of the foetus ( Fig. 
99), and when the blunt one is used the neck is merely broken 




Fig. 97. — Impacted shoulder presentation. Delivery in this position is impossible and, 
unless it can be corrected, decapitation will be necessary. 



fa 



with a twisting motion and the operation completed with Ion 
heavy scissors (Fig. 100). If the sharp hook is employed, all 
the tissues of the neck are severed with this instrument alone. 
It is also quite possible to perform the entire operation with 
the scissors, and many surgeons do not use either hook at all. 




Braun's key-hook. 



Evisceration is accomplished with the long stout scissors 
shown in Fig. 100. 

After any form of operative delivery the danger of post- 
partum hemorrhage is always to be especially feared, and the 
nurse should have ready an ample supply of hot and cold sterile 
water for douches or infusions, in case they are needed, and a 



198 A NURSE'S HANDBOOK OF OBSTETRICS. 




Fig. 99.— Braun's hook applied. (Garrigues.) 




Fig. 100.— Long, blunt scissors. For d 



ecapitation and evisceration. 



INDUCTION OF LABOR. 199 

number of hot-water bottles with which to surround the patient 
in case she goes into shock. 

The induction of premature labor is often indicated in 
cases of slight pelvic deformity, and is usually performed at 
about the end of the eighth month of gestation. In these cases 
there is no need of special haste, and the surgeon merely adopts 
such measures as will excite contractions of the uterus, after 
which the labor proceeds as in any normal case at term. 

There are three methods in ordinary use for starting up labor- 
pains. These are : the introduction of an elastic bougie, about 
the size of a lead-pencil (Fig. 101), into the uterus; packing the 



Fig. ioi. — Bougie for the induction of labor. About the size of a lead-pencil (No. 12, 

American scale). 



cervix and vagina with gauze; and the use of an elastic bag 
of small size, which is passed into the cervix, distended with 
water, and allowed to remain until uterine contractions force 
it out. 

The first, or " Krause," method is the one most commonly 
employed, and is perfectly safe. Its objections are its uncertainty 
and the danger of rupturing the membranes and causing " dry 
labor." The bougie should be about the size of a lead-pencil 
(No. 12, American scale), with a wire stylet to facilitate its intro- 
duction, and it is prepared for use by soaking it for twenty-four 
hours in cold bichloride solution (1 to 1000) after it has been 
thoroughly washed with soap and water. 

The patient is usually placed in the lithotomy position (see 
Fig. 124) at the edge of the bed or table, but some physicians 
prefer Sims's position (Fig. 102) in these cases. No anaesthetic 
is required, as the operation is absolutely painless and of but a 
moment's duration. 

Labor-pains usually begin in from thirty minutes to twelve 
hours after the insertion of the bougie. If there are no develop- 
ments at the end of twenty-four hours, it may be removed by 
the surgeon and inserted in a new place, or a second bougie 



200 A NURSE'S HANDBOOK OF OBSTETRICS. 

may be passed in alongside of the first. In some cases it is neces- 
sary to use three bougies before labor-pains begin. Gauze is 




Fig. 102. — Sims's position. The patient lies on her left hip, her chest nearly flat on the 
table, her left arm hanging- over the edge and her right leg drawn well up above the left 
knee. 

required to pack the vagina after the introduction of the bougie, 
but the physician usually supplies everything of this sort him- 
self. 

None of the methods named for the induction of labor is 
at all painful, and after the bougie, gauze, or bag has been in- 
serted the patient may be up and on her feet as in the first stage 
of normal labor. 

If the membranes rupture, the nurse should report the fact 
at once to the physician, and he should be notified, as in any 
other case, the moment true labor-pains are established. 

With the exception that these cases are artificially started, 
they do not differ in any respect from ordinary labor, nor do 
they subject either mother or child to any greater danger. 

When haste in delivery is an essential factor, as in eclampsia 
or hemorrhage, the surgeon dilates the cervix under complete 
anaesthesia, either manually or with bags, and delivers by for- 
ceps or version. As version offers the most rapid means of 
delivery at our command, it is usually the method chosen. 



XVII 

Accidents and Emergencies 

The accidents and emergencies of obstetrics may affect eithei 
the mother or the child, and may occur during the pregnancy, 
the labor, or the puerper'nnn. 

In pregnancy the conditions that may affect the mother and 
call for prompt action- on the part of the nurse are eclampsia, 
syncope, hemorrhage, and miscarriage. 

Eclampsia is a most serious complication occurring during 
the last three months of gestation, and is characterized by gen- 
eral cedema, convulsions, and coma. It must be differentiated 
from epilepsy and hysteria, and its management by the nurse is 
fully discussed in Chapter VII. 

Syncope is usually an unimportant matter, unless it is due 
to uraemia, and is often associated with anaemia or hysteria. 
The patient should be placed on her back, with no pillow under 
her head ; her clothing loosened, especially at the waist, until 
all constriction is removed ; ammonia applied to her nose ; and, 
as soon as she has recovered sufficiently to be able to swallow, 
whiskey or some other stimulant administered by the mouth. 
Patients who are subject to attacks of fainting during pregnancy 
should avoid hot, crowded rooms and every form of excitement, 
and be under the direct supervision of a physician at all times. 

Hemorrhage during pregnancy, if occurring only in the first 
three months and of the menstrual type, is not necessarily of any 
consequence, but it should be reported to the physician in view 
of the possibility that it may be one of the early symptoms of 
ectopic gestation. 

Hemorrhage occurring late in pregnancy may be due to pla- 
centa praevia, to the accidental detachment of a normally situated 
placenta, or to the rupture of an ectopic gestation sac. Bleed- 
ing due to placenta praevia is termed " unavoidable" hemorrhage, 
because, from the very nature of the case, it is bound to occur, 



2C)2 A NURSE'S HANDBOOK OF OBSTETRICS. 

sooner or later; while that caused by the accidental separation 
of a normally situated placenta is called " accidental" hemor- 
rhage, since it need not necessarily have occurred except for 
the accident that caused the detachment of the placenta from the 
uterine wall. 

Unavoidable hemorrhage (that due to placenta praevia) is 
always external, and the first symptom of this complication is 
the sudden gush of bright-r f ed blood unaccompanied by pain and 
dependent upon no discoverable exciting cause. The mere posi- 
tion of the placenta at or near the internal os uteri is sure to 
cause bleeding either at or before the beginning of labor. 




Fig. 103.— Concealed hemorrhage. The blood has collected between the placenta and the 
uterine wall, and the patient may bleed to death inside her own body. 

Accidental hemorrhage may be either external or concealed, 
and is accompanied by severe tearing pain at the site of the 
placental separation. In the concealed type the uterus merely 
bleeds into itself (Fig. 103), and the condition can only be recog- 
nized by the severe pain in the uterus and the general symp- 



HEMORRHAGE. 203 

toms of hemorrhage, — namely, collapse, extreme pallor, feeble, 
rapid pulse, disturbances of sight and hearing, excessive thirst, 
and " air hunger." 

Hemorrhage due to the rupture of the sac in ectopic gesta- 
tion is always concealed, the blood escaping into the abdominal- 
cavity and the patient suffering from pain of an excruciating 
character on the affected side, accompanied by collapse and the 
general symptoms of hemorrhage mentioned in the preceding 
paragraph. The gestation sac in ectopic pregnancy usually rup- 
tures not later than the fourth month, a period too early for pla- 
cental separation to occur, and this fact is an important factor 
in the differential diagnosis between the two conditions. 

All that the nurse can do in any case of severe hemorrhage 
during pregnancy is to send at once for the nearest physician ; 
put the patient in bed, flat on her back, with as little delay or 
excitement as possible; give a hypodermic injection of mor- 
phine (one-sixth grain), repeating it in fifteen minutes if the 
pain is severe and the hemorrhage not due to placenta prsevia; 
make immediate preparations for an operative delivery, or, if 
the case is one of ectopic gestation, for an abdominal section; 
and provide sterile normal salt solution (six-tenths per cent.) 
in ample quantity for infusion. 

It is needless to say that everything must be done in as quiet 
and methodical a manner as possible, and that no knowledge 
of the serious nature of the case must be permitted to reach the 
patient. 

Preparations for operation must be made in an adjoining 
room, and all members of the family who, by their manner, 
would have a tendency to frighten the patient and arouse her 
suspicions must be excluded from her presence on some pretext 
or other. 

Miscarriage may occur at any time during pregnancy, 
either as a result of a blow, fall, or other injury, or from an 
unknown cause. Any of the acute febrile diseases may cause 
miscarriage, and this accident is certain to occur if the patient's 
temperature rises to 105 ° F. Any pregnant woman suffering 
from a febrile disease may be expected to miscarry if the tern- 



204 A NURSE'S HANDBOOK OF OBSTETRICS. 

perature rises to the point mentioned, and whenever the nurse 
sees that the fever is steadily increasing she should make such 
preparations as will be necessary when the miscarriage occurs. 

Miscarriage is seldom if ever accompanied by any immediate 
danger to the patient, although its remote effects may be very 
serious, but the patient is often greatly alarmed at the accident, 
and the nurse must do all in her power to allay her fears and 
make her comfortable in mind as well as in body. 

The first symptom of miscarriage is pain which greatly re- 
sembles that of labor and is often equally severe. This is soon 
followed by the escape of a bloody discharge from the vagina, 
and the diagnosis is positive. 

The woman should be put to bed at once and given a hypo- 
dermic injection of morphine (one-sixth grain), and in some 
cases this will be enough to check the contractions of the uterus 
and the case may go on to full term in spite of the threatened 
interruption. The physician should, of course, be summoned at 
the first appearance of symptoms, and if the miscarriage occurs 
in spite of every effort to prevent it, he will usually wish to 
perform' a thorough curettage at once. The preparations for 
this operation are described in Chapter XXI. 

Death of the fcetus during pregnancy is usually followed 
by miscarriage, and it is only under these circumstances that it 
can be regarded in the sense of an emergency. 

Occasionally the dead infant is retained in the uterus for a 
considerable period, and when this occurs the diagnosis of the 
condition is often extremely difficult. The symptoms that point 
to the death of the foetus are cessation of fetal heart sounds and 
active movements, general malaise of the mother, the occasional 
appearance of a foul-looking, though not necessarily offensive, 
discharge from the vagina, dull pain in the back and limbs, and 
shrinking and general flabbiness of the breasts and abdomen. 

The physician should be notified if these suggestive symp- 
toms develop, and if he finds, on examination, that the child 
is actually dead, he will usually proceed to empty the uterus at 
once. 

During labor the mother may suffer from eclampsia, hemor- 



RUPTURE OF THE UTERUS. 



205 



rhage either from placenta prsevia or placental separation, rup- 
ture of the uterus, inversion of the uterus, and sudden death 
from heart failure or other cause due to intercurrent constitu- 
tional disease. 

Eclampsia and hemorrhage have already been sufficiently 
discussed, and as the physician will usually be in attendance at 
this time, the nurse will be relieved of all responsibility. 




Fig. 104. — Rupture of the uterus. The specimen is opened opposite the laceration in 
its wall (A), and the points (B B) indicate the ends of the severed cervical ring. The 
roughened area of placental attachment is plainly seen at the upper part of the uterine cavity. 



Rupture of the uterus (Fig. 104) often resembles greatly 
the concealed hemorrhage of placental separation, the general 
symptoms of shock and collapse being common to both condi- 
tions, but the essential difference is that placental detachment 
occurs before or early in labor, while rupture of the uterus can 
only happen after the woman has been in severe labor for a con- 
siderable time. If the foetus escapes through the tear into the 



206 



A NURSE'S HANDBOOK OF OBSTETRICS. 



abdominal cavity, Cesarean section will be necessary for its 
removal, while if it can be delivered through the natural pas- 
sages by forceps or version, the surgeon may either open the 
abdomen and sew up the rent, or pack the uterine cavity through 
the vagina with gauze and leave the healing of the wound to 
nature. As the treatment by packing gives, in the general run 
of cases, as satisfactory results as the more radical abdominal 
operation, it is the one most commonly employed. 



~m 



-x-j*-> 



I — 





Fig. 105.— Complete inversion of the uterus. (Boivin and Duges.) b, right labium 
majus; c, right labium minus; d, clitoris; e, meatus;/, anterior vaginal wall; g, external 
os uteri ; h, internal surface of inverted uterus. 



Inversion of the uterus is one of the rarest accidents of 
labor, but it may occur in any degree, from a mere sinking 
down of the fundus to an actual turning inside out of the entire 
organ (Fig. 105). It may follow operative delivery, or it may 
be due to shortness of the umbilical cord, either actual, or rela- 



PROLAPSE OF THE CORD. 207 

tive by being wrapped about the infant's body, which drags 
down the placenta and with it the adherent uterine wall. 

After the child is born, inversion may be caused by pulling 
on the umbilical cord to extract the placenta, or, if the uterus 
is empty and relaxed, by improper pressure on the fundus or 
violent straining or coughing by the mother. These last-men- 
tioned cases might better be classed as accidents of the puer- 
perium, but the complication is of such extreme rarity at any 
time that it need only be mentioned in this place. 

The symptoms are severe pain at the point of inversion, 
hemorrhage which is more severe as the inversion is greater, 
faintness or actual syncope, collapse, and pain in the rectum 
and bladder. 

The treatment consists in replacing the inverted portion of 
the womb, and is easier the more promptly it is performed. It 
cannot be attempted by the nurse. 

Heart failure and other conditions of a like nature which 
greatly endanger the patient can, in the absence of the physician, 
only be treated by the prompt and energetic administration of 
stimulants, such as whiskey, strychnine, and nitroglycerin, by 
the hypodermic needle. 

The child may be endangered during labor by malposition, 
prolapse of the umbilical cord, and asphyxia from protracted 
or instrumental delivery. The only malpositions which the 
nurse can be expected to recognize are those accompanied 
by prolapse of an arm or leg, but if she finds an extremity 
protruding from the vagina she will, of course, know at once 
that the case is a serious one and send immediately for the 
physician. 

If the cord prolapses and descends in front of the present- 
ing part (Fig. 106), the accident is usually due to premature 
rupture of the membranes when the head or breech is not 
sufficiently down in the pelvis to prevent the cord from being 
washed past it in the sudden gush of amniotic fluid. Unless 
the cord is carried down to the vulvar orifice, the nurse is not 
likely to know that this complication has arisen, for in private 
practice she is not expected to make any vaginal examinations 



2o8 A NURSE'S HANDBOOK OF OBSTETRICS. 




Fig. 106. — Prolapse of the umbilical cord. (Bumm.) As the head comes down the com. 
pression of the cord between the fetal skull and the pelvic brim will shut off its circulation 
completely. 




Fig. 107.— Knee-chest position. (Potter). The back must be straight or slightly concave 
and the thighs perpendicular. 



TRENDELENBURG POSITION. 



209 



whatever, exeept for speeial reasons of the utmost urgency. If, 
however, she knows that the cord has prolapsed, she should 
send at once for the physician and then put the patient in the 
" knee-chest" position (Fig. 107), or in the Trendelenburg posi- 




FiG. 108. — Trendelenburg position. 



tion (Fig. 108), to favor its return into the cavity of the uterus. 
If the pulsations in the cord cease or even grow feeble or 
irregular, there can be no objection to an attempt at its reposi- 
tion with the hand. 

With the patient in one or the other of the positions named, 
the nurse should pass her entire hand, thoroughly scrubbed and 
disinfected and well lubricated with sterile vaseline or lubrichon- 
drin, into the vagina and try, with the utmost gentleness, to 
push the cord up into the uterus past the presenting part until 
it falls entirely out of reach. This is often a very difficult thing 
to do, on account of the tendency of the cord to prolapse as soon 
and as often as it is replaced, but if the nurse has been thorough 
in the disinfection of her hands and in her observance of all 
the rules of asepsis no harm can result from the attempt, and 
it may be the means of saving the infant's life. The patient's 

H 



210 A NURSE'S HANDBOOK OF OBSTETRICS. 

hips must be kept raised above the level of her shoulders, or 
the cord will be almost certain to come down again into the 
vagina, and this can best be accomplished by placing a thick 
pillow or cushion under her buttocks, for it will be found quite 
impossible for her to remain in either the " knee-chest" or the 
Trendelenburg position for any length of time. In changing 
to the dorsal posture the patient must exercise the greatest 
caution, and the pillow or cushion must be ready to place under 
her the moment she is on her back. As soon as this change in 
position has been accomplished the nurse should, with every 
antiseptic precaution, again insert her hand into the vagina to 
make sure that the cord has remained above the pelvic brim. 

It is, of course, assumed that every effort has been made to 
secure the services of some physician, even other than the regu- 
lar medical attendant, before any manual correction of this 
condition has been attempted by the nurse. If a physician 
can be secured within a reasonable length of time nothing 
should be done by the nurse beyond putting the patient in the 
" knee-chest" or the Trendelenburg position and awaiting his 
arrival. 

Asphyxia neonatorum (asphyxia of newly born infants) 
may result from injury during manual or instrumental delivery; 
from compression or torsion of the umbilical cord, shutting off 
the fetal blood-current; or from protracted labor alone. Any 
one of these conditions should be enough to suggest the proba- 
bility that the child will be born in a state of suspended anima- 
tion, and preparations for its resuscitation should be made, if 
possible, before the termination of the labor, so that there will 
be no delay whatever. 

The nurse should have ready two large pans or foot-tubs, 
one containing hot water (105 F.) and the other ice-water and 
a good sized piece of ice. These should be placed side by side 
on chairs or on a low table at a distance from the mother's bed, 
or even in another room. In addition there should be a soft 
rubber catheter, about the size of a lead-pencil, for withdrawing 
mucus from the infant's throat, and a number of pieces of 
gauze, about eight inches square, for wiping out the mouth 



ASPHYXIA NEONATORUM. 2il 

or for placing over the face if it is deemed necessary to blow 
air directly into the baby's lungs. 

There are two types of asphyxia neonatorum. In one the 
baby's face and even its entire body are of a livid hue and the 
vessels of the umbilical cord are gorged with blood; in the 
other the child's face and body are of a death-like pallor and 
the vessels of the cord are empty. 

The livid cases usually recover, for the lividity only indi- 
cates an early stage of asphyxiation, but while the pallid infants 
may occasionally be made to breathe after prolonged efforts, the 
majority of them die at once or after a few days. 

If a child is born in an asphyxiated condition the cord should 
be tied and cut at once, so that there will be no interference with 
the performance of artificial respiration and to permit the 
adoption of immediate measures towards its resuscitation. 

No time is to be wasted in determining whether it is dead 
or alive. It is always to be assumed that the child is living, 
for often it is over an hour before breathing can be established, 
and cases are on record where success has followed efforts 
extending over the enormous period of seven or eight hours. 
Moreover, even if the child is dead, it is a satisfaction and com- 
fort to its parents to know that every possible effort was made 
to save it. 

There are many methods of performing artificial respiration 
on the newly born infant, but a description of one and its clear 
understanding by the nurse is all that is necessary in this place. 

The first thing to do is to hold the infant up by its heels 
(see Fig. 64), slap it sharply on its back and chest, and insert 
a finger in its mouth to the back of its throat and remove any 
mucus or blood that may be there. 

The child should next be dipped up to its neck in the hot 
water, held there for a moment or two, then transferred to the 
cold water for an instant, and back to the hot. While it is still 
in the hot water artificial respiration should be practised in the 
following manner : 

The child is held with the right hand of the nurse under its 
shoulders and its neck lying in the cleft between the thumb 



212 A NURSE'S HANDBOOK OF OBSTETRICS. 

and forefinger, with the head falling- loosely backward. The 
left hand of the nurse supports its thighs, and its entire body, 
with the exception of its head, is submerged in the hot water. 
This means, of course, that the nurse's hands are both under 
water. 

Expiration is now affected by doubling up the body of the 
infant until its knees almost if not quite touch its chest. It is 
held a moment in this position, and then inspiration is caused 
by separating the hands and bending the body backward as far 
as possible. This process is repeated about twelve times a 
minute, or once in every five seconds, and by placing her ear 
close to the baby's mouth when the movement of expiration is 
performed the nurse can tell if the manipulation is effective 
and air is actually being forced in and out of the lungs. Every 
few minutes the child is to be plunged into the cold water and 
returned instantly to the hot, in the hope that the shock will 
stimulate natural respiratory movements of the chest, and from 
time to time a finger is to be passed into its mouth to free it 
from mucus or other obstructing substance. 

If its heart action is very feeble or irregular, or if no beats 
at all can be heard by placing the ear in close contact with the 
chest wall, a hypodermic injection of whiskey (ten minims) 
should be given, and if no air can be made to enter and leave 
the lungs when the artificial respiration is performed the air- 
passages may be expanded by laying a piece of gauze over 
the infant's face and, with the lips in close contact with its 
mouth, blowing a short, sharp blast down its throat. As soon 
as this has been done the artificial respiration is to be resumed 
and contmued for at least an hour in the manner already de- 
scribed. 

If at the end of this time there are still no signs of life, 
it is hardly probable that anything further can be accomplished, 
but it is usually wiser to continue the efforts for a somewhat 
longer period, if for no other reason that to satisfy the family. 

The physician will, of course, attend to this matter of resus- 
citating the infant if the condition of the mother is such that 
he can leave her with safety, but often the task will fall to the 



RETAINED PLACENTA. 213 

nurse, and in some cases, even after the physician has officially 
pronounced the child dead, the family will be gratified at further 
efforts to save it, futile though they be. 

During the puerperium the conditions affecting the mother 
which can be classed as accidents and emergencies are eclampsia, 
retained placenta, hemorrhage, and embolism, or " heart clot." 

Eclampsia has already been fully discussed, but it must be 
remembered that when this complication originates after the 
birth of the child it is of a far more serious nature than when 
it occurs before or during labor. Under the latter circum- 
stances it may usually be relieved by the prompt emptying of 
the uterus, but when the convulsions appear for the first time 
after the child is born it shows that the constitutional poisoning 
is of an exceptionally virulent type, and there is nothing to 
do beyond controlling the convulsions with chloroform and 
fighting the attack in the manner described in Chapter VII. 

The nurse will, of course, summon the physician at once if 
eclamptic convulsions appear, and she must be on her guard 
that the spasms are not due to excessive hemorrhage. There 
should be no difficulty whatever in distinguishing between the 
two conditions, for the convulsions due to hemorrhage do not 
appear until the body is practically bloodless and just before 
death supervenes, while in eclampsia the patient's face is flushed 
or even cyanotic and the pulse is full and hard. 

Retained placenta is not a serious condition unless the 
presence of the after-birth in the uterus prevents firm contrac- 
tion of the womb and causes severe hemorrhage. Even in these 
cases there is usually time to await the arrival of the physician, 
for it is assumed that he was summoned at the onset of labor, 
and it is not to be supposed that he will leave before the placenta 
is delivered. Firm pressure is to be maintained on the fundus, 
which is to be kneaded vigorously whenever it shows signs of 
relaxation, and it is hardly probable that enough blood will be 
lost to affect the patient seriously. If the bleeding becomes 
alarming, as shown by the amount of the flow and the general 
condition of the patient, and no physician can be secured, the 
nurse may, after the most careful disinfection of her hand, pass 



214 



A NURSE'S HANDBOOK OF OBSTETRICS. 



it gently into the vagina up to the cervix, grasp the placenta 
firmly in her fingers and remove it slowly and with a deliberate 
twisting motion (Fig. 109). If it is still adherent to part of the 




Fig. 109.— Manual extraction of the placenta. (Garrigues.) This must never be attempted 
by the nurse, except for urgent reasons and after most careful aseptic precautions. 

uterine wall, two or three fingers are to be carried into the 
womb, between it and the placenta, and the tissues separated 
much as one would separate the sections of an orange. When 
the entire organ has been detached in this way, it is to be 
grasped in the palm of the hand and withdrawn carefully. If 
all antiseptic precautions have been faithfully observed this 
manoeuvre will do no harm, but it must be distinctly understood 
that it is a dangerous thing to do, and one never to be attempted 
by the nurse except in the gravest emergency when no physician 
at all can be obtained. 

Hemorrhage other than the type just mentioned may be due 
to laceration of the cervix or to uterine inertia. 

Hemorrhage due to cervical laceration is almost invariably 
caused by instrumental or manual delivery, and seldom if ever 
by spontaneous labor. The bleeding appears the instant the 
child is extracted from the vagina, and in rare instances may 
be of sufficient severity to greatly endanger the mother. If the 
fundus is firm and well contracted and the blood continues to 
flow freely, the diagnosis is very simple. 



POST-PARTUM HEMORRHAGE. 215 

Fortunately for the nurse, the physician is usually present 
when this accident occurs, and the management of the case rests 
entirely with him. Occasionally it is necessary to bring the 
torn edges of the cervix together with one or two chromicized 
catgut sutures in order to check the bleeding, but in many 
cases snug packing of the vagina with gauze will be found 
effectual. 

Whether the cervix is to be sutured or the vagina merely 
packed, the patient should be turned crosswise in the bed with 
her buttocks well over the edge and her legs supported in the 
lithotomy position, either in a leg holder or by assistants. 

If packing is the method of treatment employed, the nurse 
must watch the fundus with special care during the next few 
hours, lest hemorrhage continue into the cavity of the uterus. 
The packing should never be left in the vagina for more than 
twenty-four hours, and in many cases it is better to remove it 
at the end of twelve hours, as it almost invariably interferes 
with natural urination and makes catheterization extremely 
difficult. 

If the hemorrhage has been at all severe the nurse should 
prepare hot (118 F.) sterile normal salt solution (one tea- 
spoonful to the quart) for infusion, arrange for elevating the 
foot of the bed, and provide an ample number of hot-water 
bottles (beer-bottles with patent stoppers in an emergency) 
with which to surround the patient. 

Post-partum hemorrhage, in the ordinary acceptance of 
the term, is that which occurs from the cavity of the uterus after 
the birth of the child and either before or after the delivery of 
the placenta. It is due in almost every case to relaxation of 
the uterus (uterine inertia), and may usually be prevented if 
proper attention is paid to the management of the fundus during 
the hour that immediately follows the delivery of the infant. 

It is apt to occur in severe cases of albuminuria or other 
constitutional disturbance; it frequently follows operative de- 
livery or prolonged and exhausting natural labor; and it may 
occur in any case from no discoverable cause, unless it be care- 
lessness in holding the fundus. Consequently, the occurrence 



2i6 A NURSE'S HANDBOOK OF OBSTETRICS. 

of post-partum hemorrhage is to be regarded as a possibility 
after every case of labor, no matter how simple and normal its 
course may have been, and, as Dr. Gooch has said, " No physi- 
cian should have the assurance or hardihood to cross the thresh- 
old of a lying-in chamber who is not thoroughly conversant with 
the remedies for flooding." 

Unfortunately, there are many physicians who, although 
they may be as " thoroughly conversant with the remedies for 
flooding" as Dr. Gooch in his most exacting mood could desire, 
neglect systematically to provide themselves with the necessary 
drugs and appliances to meet this condition effectively. Nearly 
every case of post-partum hemorrhage that passes beyond con- 
trol may be accounted for by the neglect of some one to have 
ready the necessary articles for checking it at its very outset, 
and it may safely be said that there is no variety of hemorrhage 
that should be so amenable to the surgeon's skill as the one 
under consideration. 

The physician who attends obstetric cases with no other 
equipment than a vial of ergot, a bichloride tablet, and a pair 
of forceps in a little black bag is rapidly being relegated to the 
obscurity which he deserves, and his disappearance from society 
will be of untold benefit to the mothers of the future. 

Post-partum hemorrhage is usually external, or largely so, 
but when it occurs before the delivery of the placenta it may, 
in good part, be concealed within the cavity of the uterus. The 
concealed type can never occur if the fundus is properly held, 
for the blood will necessarily be squeezed out of the womb into 
the vagina and escape into the bed. 

When, however, the uterine tissue is so inert that, although 
it may be compressed and the walls of the womb approximated 
by the pressure on the fundus, the muscular fibres refuse to con- 
tract and close the blood-vessels, the condition is a most alarm- 
ing one. and in severe cases may cause death within a few 
minutes. 

As a rule, if hemorrhage does not occur within an hour after 
the birth of the child, especially when the fundus has been 
properly managed, it will not occur at all, but it may develop 



POST-PARTUM HEMORRHAGE. 



217 



twenty-four hours or even longer after delivery, and the nurse 
will be called upon to meet the emergency without a moment's 
delay. 

In cases which occur before the departure of the physician 
he will usually pack the uterus firmly with strips of iodoform 
(five per cent.) or sterile gauze, if the administration of ergot, 
vigorous kneading of the fundus, and a hot (120 F.) sterile 
or saline douche do not check the flooding at once. Every 
physician should have gauze for tamponing the uterus in his 
maternity outfit, and the nurse should have ready, at every labor, 
a sufficient quantity of hot sterile water or saline solution for 
use at a moment's notice. 

The patient is to be brought to the edge of the bed, in the 
lithotomy position, and if the physician decides to pack the 
uterus he will grasp the anterior lip of the cervix with a volsel- 
lum or bullet-forceps (Fig. 131), draw it down to the vulva, and 
have the nurse steady it in this position while he inserts the 
gauze. Hot salt solution for infusion or rectal irrigation must 
be provided at once, the patient laid flat on her back, without a 
pillow, and surrounded with hot-water bottles, the foot of the 
bed elevated, and hot water with whiskey or brandy given by the 
mouth unless there is vomiting. 

If hemorrhage occurs when the nurse is alone, she should, 
of course, send at once for the first physician that can be 
reached. 

In many cases her attention will be directed to the condition 
by the patient herself, who will complain that she is " flooding," 
and inspection will show a pool of blood (possibly a pint or 
more) in the bed. At other times the suspicions of the nurse 
will be aroused by the pallor of the patient's face, and on 
raising the bedclothes the evidences of severe bleeding will be 
found as before. 

The first thing to do, after sending a messenger hastily for 
the nearest physician, is to grasp the fundus, if it can be found, 
and knead it energetically. If ergot is to be had, some one 
should be directed to give the. patient a teaspoonful by the mouth. 
If the nurse has equipped herself according to the directions 



2i8 A NURSE'S HANDBOOK OF OBSTETRICS. 

given in Chapter X., she will have tablets of ergotin in her 
outfit, and, instead of the fluid preparation, two grains of ergotin 
dissolved in one drachm of water may be injected hypodermi- 
cally into the outer side of the thigh. The vigorous rubbing of 
the fundus is to be kept up while some one is despatched for 
hot water and salt, and if a piece of ice can be secured promptly, 
it may be rubbed briskly over the belly to stimulate uterine con- 
traction while awaiting the arrival of the hot water. 

As soon as the materials for the douche are at hand the 
water is to be brought to the temperature of 120 F. (or as hot 
as the hand can bear) by the addition .of cold if necessary, a 
teaspoonful of salt added to each quart, and the solution injected 
freely into the uterus, while the hand on the abdomen still exerts 
pressure on the fundus. 

If, in spite of this, the uterus remains flabby and the bleed- 
ing continues to an excessive degree, the nurse should take a 
clean handkerchief or napkin (preferably a new one), if no 
gauze is available, soak it in vinegar, and thrust it boldly 
through the vagina into the uterus and up to the fundus. While 
the hand is in the uterus a rapid search should be made for any 
possible fragments of retained placenta, and if any are found 
they must be removed, as well as all blood-clots, so that the 
cavity of the womb shall be entirely empty. The cloth soaked 
in vinegar is to be left in the uterus only long enough to stimu- 
late strong contractions, when it is to be removed carefully, 
together with all clots and placental tissue that may be present. 

If this manoeuvre fails and no physician has arrived, and if 
the condition of the patient continues to grow more and more 
alarming, the only remaining hope is to pack the uterus. 

The nurse cannot be expected to do this as expeditiously or 
as effectively as the physician, but if she has in her the stuff 
that heroines are made of, and keeps cool and collected, she 
may, in a desperate case, be the means of saving a life that 
would otherwise inevitably be lost. She will not have proper 
materials for packing nor instruments for the introduction of 
the tampon, but there is no time to be lost and she will have 
to do the best she can. If she has plain gauze, well and good ; 



POST-PARTUM HEMORRHAGE. 219 

if not, she must use a clean sheet ; either of which is to be torn' 
in strips three inches wide and as long" as the material will 
allow. A gauze bandage of this width makes good packing 
material, and occasionally can be secured on short notice. 

While some one presses the fundus down so that the cervix 
will appear at the vulva, the nurse can, with her hand, force 
the gauze into the uterus in loops of about six inches at a time 
until the cavity is entirely filled, after which the vagina is to 
be packed with equal firmness. 

It will be noticed that nothing has been said about antiseptic 
precautions of any kind. It is, of course, assumed that the 
rules of surgical cleanliness will be followed as far as the cir- 
cumstances will permit, but in those cases where the question 
of life or death must be decided within a very few minutes the 
hemorrhage must first be controlled at any cost and the septic 
infection, if it occurs, combated afterwards. 

As soon as the uterus and vagina are packed the patient is 
to be placed on her back with no pillow, surrounded with hot- 
water bottles, and the foot of her bed elevated. A quart of hot 
salt solution (118 F.) is to be injected slowly into her rectum, 
as high up as possible, to be absorbed and take the place of the 
blood lost, and this may be repeated every half-hour if necessary. 

Stimulation, in the form of whiskey, one drachm, strychnine, 
one-sixtieth grain, or nitroglycerin, one one-hundredth grain, 
necessary to bandage the arms and legs snugly from below 
is to be given hypodermically as indicated, and it may be 
upward to force the blood out of the extremities into the trunk. 
These bandages should never be allowed to remain for more 
than two hours, and they are to be removed with great caution, 
one at a time, to avoid the danger of collapse. 

If the patient still fails to respond to treatment, subcutaneous 
infusion of normal salt solution should be performed as follows : 
A pint of the solution, at a temperature of ioo° F., is placed 
in an ordinary douche-bag or fountain syringe and hung about 
three feet above the level of the patient's body. An ordinary 
hypodermic needle (the larger the better, and, best of all, an 
aspirating needle, Fig. no) is attached to the end of the tubing, 



220 



A NURSE'S HANDBOOK OF OBSTETRICS. 






and as soon as the liquid begins to flow the needle is thrust for 
its entire length into the chest at the base of the breast, parallel 



Fig. iio. — Aspirating Needle. 



to the surface of the body (Fig. in). Gentle massage should 
be practised as the solution distends the tissues, and the needle 
should be moved about from time to time and occasionally with- 




Fig. in. — Saline infusion under the breast. The bag should hanj 
level of the bed or table. 



three feet above the 



drawn and inserted in a new place. The time required for the 
infusion of a pint of solution in this manner will be from ten to 
twenty minutes according to the size of the needle, and fresh 



SALINE INFUSION. 221 

hot solution should be added at occasional intervals to keep the 
temperature up to the required point (ioo°). 

It is needless to say that the apparatus and the solution 
must be sterile, and the skin at the site of the infusion is to be 
wiped off with alcohol or some antiseptic preparation. 

The method of treatment outlined here is carried to comple- 
tion to cover those cases in which no physician at all can be 
secured, but the nurse must exert every effort to obtain the 
services of some medical man at the earliest possible moment 
who will take charge of the case and relieve her of any further 
responsibility. 

Although a condition that is preventable in almost every 
properly managed case, post-partum hemorrhage is one of the 
most terrible complications that can arise in any branch of sur- 
gery, and the nurse who can, by her own efforts, bring a patient 
out of this emergency is worthy of all honor and respect. 

Embolism, or " heart clot," may be formed originally in the 
right ventricle, or may be due to a thrombus washed along in 
the blood-current until it is lodged in the heart. The clot 
obstructs the passage of blood into the lungs, either wholly or in 
part, and the patient may die of asphyxia within a few minutes. 

The condition may follow severe hemorrhage, septic infec- 
tion, shock, or general exhaustion, and may occur at any time 
during the puerperium. 

The entrance of air into the circulation through the uterine 
vessels, either from the careless administration of a douche or 
from the decomposition of septic matter within the womb, 
presents practically the same symptoms and calls for the same 
treatment as heart clot. 

The symptoms are sudden, severe pain over the heart, great 
dyspnoea, syncope, feeble, irregular pulse, or none at all, pallor in 
some cases and cyanosis in others, and death at any time within 
a few minutes to a few hours, according to the amount of 
obstruction to the pulmonary circulation. Very few cases 
recover. 

The treatment consists, first, in preventing the accident by 
careful attention to all the details in the proper management of 



222 A NURSE'S HANDBOOK OF OBSTETRICS. 

every obstetric case, and secondly, if the complication arises, in 
the free administration of whiskey and strychnine and the main- 
tenance of absolute quiet on the back, for the slightest move- 
ment may result fatally. 

If the patient survives the attack, the body temperature must 
be kept up by the use of hot-water bottles, absolute rest en- 
joined, and a light, nourishing diet given, in the hope that she 
can be kept alive until the clot is absorbed. 

The only obstetric emergency that can affect the child after 
its birth is secondary hemorrhage from the navel or cord. 

If the blood escapes through the vessels of the cord before 
it has separated from the body, a fresh ligature is to be applied 
and tied tightly and carefully. 

If the blood comes from the navel itself at the base of the 
cord, either before or after its separation, it can usually be 
controlled by firm pressure with hot compresses (no° F.) until 
the arrival of the physician. The treatment which he will prob- 
ably adopt if the hemorrhage is severe and continues for a long 
time is to transfix the base of the navel with two long needles 
inserted at right angles to each other and compress the vessels 
against them with a tight " figure-of-eight" ligature. 




Fig ii2.— Figure-of-eight ligature. For controlling secondary hemorrhage from the 

umbilicus. 

In rare cases, where no physician can be secured, the nurse 
may have to do this herself.- Every antiseptic precaution is to 
be faithfully observed, and the needles (darning needles will 
answer) and silk or bobbin tape must be boiled. 

The navel is to be pinched up with the thumb and forefinger 
and a needle thrust through its base from side to side at a 



UMBILICAL HEMORRHAGE. 223 

depth of about one quarter of an inch. The second needle is 
then to be inserted in the same manner, at right angles to the 
first, and the ligature passed tightly over the ends in " figure-of- 
eight" loops and drawn up until every vestige of bleeding, or 
even oozing, has ceased (Fig. 112). The needles may be re- 
moved at the end of six or eight hours, but the ligature should 
be allowed to remain and come off when it will. 

The dressings should be changed daily and the most rigid 
antiseptic precautions must be observed until the parts are 
entirely well. 



XVIII 

The Physiology of the Puerperium 

The puerperium, also called the " puerperal state" and the 
" lying-in state" is practically a period of convalescence extend- 
ing from the end of the third stage of labor to the time when 
the patient has fully recovered from its effects. While, in nor- 
mal cases, it cannot properly be called a pathological condition, 
it is so nearly on the border line between health and disease that 
it must be most carefully watched lest serious complications 
develop suddenly and unexpectedly. 

Immediately after labor the patient experiences a sense of 
exhaustion, which is soon followed by a feeling of delightful 
comfort and repose. Her child is born, her sufferings have 
ceased, and she usually passes from a state of perfect content- 
ment into drowsiness, and finally into sound and natural sleep. 

Every effort should be made to encourage this state of affairs, 
and the necessary toilet of the patient and arrangement of the 
room must be made as quietly and expeditiously as possible, 
while all visitors, except possibly the husband and mother, are 
to be rigidly excluded. 

A chill occurring immediately after labor, and due partly 
to a disturbance of equilibrium between external and internal 
temperature, caused by the excessive perspiration in the stage 
of greatest muscular exertion, and partly to the sudden removal 
of a large mass of tissue from the abdominal cavity, is not of 
infrequent occurrence and has no unfavorable significance. A 
warm bed, hot-water bottles, and a drink of warm tea are all 
that is needed to control it effectually. 

The pulse of the puerperal woman should show a marked 
drop in frequency, due probably to greatly lessened arterial ten- 
sion. It usually goes down to about 60, and even a fall to 40 
beats per minute is not uncommon. This is always a favorable 
symptom, while a rapid pulse after labor is to be regarded with 
224 



PULSE AND TEMPERATURE. 



225 



suspicion as an indication of shock or possibly of concealed 
hemorrhage. 

The temperature of the lying-in woman usually rises slightly, 
and while 100.5 ° F. is generally regarded as the limit in normal 
cases, it cannot be denied that patients occasionally show a 
somewhat higher temperature without any ill effects. In judging 
of the significance of the temperature the pulse is the best guide, 
for a puerperal patient with a slow pulse is not likely to do 
badly even if her temperature is a little high. Nevertheless, the 
nurse should report at once to the physician a temperature of 
over 100.5 ° F. or a pulse of over 100, and such a patient must 
be watched most carefully for the possible development of fur- 
ther unfavorable symptoms. 

The uterus begins to return to its normal condition with the 
beginning of labor. This process is called "involution/* and 
consists partly in the contraction of the womb and partly in the 
destruction of certain of its tissues, which are carried away not 
only in the discharge of blood and serum that follows later, but 
by means of the general circulation as well. The normal process 
of involution requires about six weeks, and at the end of that 
time the uterus should be, as nearly as it ever will be, in the 
condition it was in before pregnancy occurred. It never re- 
turns to exactly the virgin state, but may approach it very closely 
if there have been no lacerations of the cervix. 

Involution is favored and hastened by everything that tends 
to make the puerperium perfectly normal, and is delayed by 
the opposite condition. It is on this account that breast-feeding 
of the infant is urged in the interest of the mother, for the reflex 
connection between the breasts and the uterus is so well estab- 
lished that the irritation of the nipple in nursing acts as a power- 
ful stimulus to uterine contractions. 

" Subinvolution" is the term used to describe the condition 
which exists when involution is not complete at the time when 
it should be. It is a chronic condition, characterized by a large 
and flabby uterus usually more or less chronically congested, 
and causes the patient much discomfort and disturbance of 
health until it is cured. 

IS 



226 A NURSE'S HANDBOOK OF OBSTETRICS. 

The vaginal walls, the vulva, and all other tissues that have 
become hypertrophied during pregnancy also undergo a process 
of involution in their return to their normal condition, and the 
abrasions and lacerations of the genital canal caused by the 
passage of the foetus heal completely during the puerperium. 

Lochia is the name given to the discharges that come from 
the uterus and vagina for about three weeks after the birth of 
the child. At first the discharge consists almost entirely of blood, 
which escapes from the placental site on the uterine wall, mixed 
with a small amount of mucus and particles of decidua. This 
is known as "lochia rubra" (red lochia) and lasts about three 
days, when it gradually changes to a pinkish color due to the 
admixture of a considerable amount of serum from the healing 
surfaces. Towards the eighth or ninth day the lochia become 
thinner, less in amount, and of a greenish-yellow color, and by 
the end of the third week the discharge usually disappears en- 
tirely. 

The lochia should never, at any time, have an offensive odor, 
although it possesses a peculiar animal emanation which is quite 
characteristic. 

Premature suppression of the lochial discharge may be 
caused by cold, fright, grief, or other emotion, and is usually 
dependent upon a relaxed condition of the uterus. 

Late return of blood in the discharge, after it has once dis- 
appeared, often occurs when the patient gets up too soon, and 
is not of any serious import if she returns to her bed for a few 
days longer. 

"After-pains" are painful contractions of the womb occur- 
ring after labor and due to its efforts to expel a blood-clot which 
has formed within it when it was in a state of relaxation. After- 
pains are more common in women whose tissues are soft and 
flabby, and so are seen less frequently in primiparse than in those 
who have borne many children. They occur at intervals, like 
labor-pains, and often are said by the patient to cause her more 
suffering than the labor-pains themselves. The proper manage- 
ment of the fundus uteri, as described in the next chapter, will 
insure firm and permanent contraction, and is the best preventive 



RETENTION OF URINE. 



227 



against after-pains. When they are at all severe they interfere 
markedly with the patient's rest and comfort, and the physician 
will usually find it necessary to remove the clot from the uterus 
to effect a cure. Under ordinary circumstances they will dis- 
appear spontaneously about the fourth day. 

Retention of urine is not uncommon during the first two or 
three days after labor, owing to the swollen condition of the 
urethra and the tissues surrounding it. Its treatment is dis- 
cussed in the following chapter. 

Constipation after labor is the rule rather than the excep- 
tion, because of the relaxed and flabby condition of the intestinal' 
and abdominal muscles and the inability of many persons to 
empty the bowels while in the dorsal position on the bed-pan. 
As the rectum has been, or should have been, emptied by enema 
at the beginning of labor, nothing further is needed until about 
two days have elapsed, when the physician usually orders a 
simple cathartic. If he neglects to do so it is proper for the 
nurse to remind him that the bowels have not moved, rather than 
take the responsibility of giving drugs on her own account. 

The appetite of the patient is usually somewhat diminished 
during the early part of the puerperium, and this, combined with 
the fact that all of her excretions are markedly increased, causes 
her to lose flesh to the amount of from nine to twelve pounds 
before she begins to gain in weight. 

" Milk fever " is a term occasionally and, possibly, incorrectly 
used to describe a slight and unimportant rise of temperature 
that occurs about the third day and subsides in a few hours. 
This was long supposed to be due to the development of milk in 
the breasts, which occurs at the same time, but it is now thought 
by many to depend entirely on a very slight infection due to the 
unavoidable introduction of a few bacteria into the genital tract. 
The author believes, however, that the mere discomfort, due to 
tension in the early days of lactation, is not infrequently re- 
sponsible for this phenomenon, independently of any infection 
whatever. It is quite a regular occurrence, and should never 
last more than a day. 



XIX 

The Management of the Puerperium 

The fundus "uteri is to be held through the abdominal wall for 
one full hour after the birth of the child. This duty may be 
performed by the physician or he may delegate it to the nurse, 
but it must never be forgotten that it is of far greater impor- 
tance than anything else that can be done at this time, and the 
nurse should never begin to put the room in order, bathe the 
patient, or wash the baby unless some one has a hand on the 
fundus. If this procedure were conscientiously and systemati- 
cally followed out in every case, post-partum hemorrhage due to 
uterine inertia would be practically unknown. 

The nurse should sit or stand by the side of the patient, facing 
her feet, and the ulnar edge (the edge on the side of the little 
finger) of the hand nearest the patient is to be pressed down 
firmly on the abdominal wall in the median line and at a point at 
about the level of the umbilicus (Fig. 113). In the relaxed and 
flabby condition of the abdominal wall after the birth of the child 
it is quite possible to force it back until the backbone can be felt, 
and the nurse never should make the mistake of not using suffi- 
cient pressure. The uterus should now be felt below, and prac- 
tically in the palm of the hand, as a firm rounded mass about 
the size and shape of a large cocoanut. If the nurse does not find 
it at once she should feel around for it, for it may be displaced 
to one side or it may have relaxed until it has lost its firmness. 
If this rapid search fails to locate the fundus, she should call 
at once for the assistance of the physician, or, if she is alone, 
redouble her efforts, watch for hemorrhage as indicated either 
by the flow or by the patient's pulse and expression of counte- 
nance (pallor, etc.), and have some one give the woman one 
teaspoonful of fluid extract of ergot if it is to be had. The 
nurse herself should not remove her hand from the abdomen, 
and the vigorous kneading of the belly caused by her efforts 
228 



MANAGEMENT OF THE FUNDUS. 



229 



to find the fundus, especially if assisted by the ergot, will usually 
be enough to make the uterus again contract firmly so that it 
can be distinctly felt under the hand. 

As long as it remains firm and hard it should be left alone, 
the hand resting against it with sufficient pressure to permit the 
immediate recognition of any tendency towards relaxation. 




Fig. 



[3. — Holding the fundus after delivery. This must be kept up for one full hour 
after the birth of the child. 



From time to time this relaxation will occur and the uterus 
grow soft and slightly flabby, but still perfectly distinct to the 
touch. On these occasions the fundus should be grasped in the 
hand and " kneaded" with a rotary motion gently but with in- 
creasing force until firm contraction occurs and the uterus is 
again hard and solid. This manoeuvre is not at all unlike that 
often practised by patronizing adults when they grasp a small 
boy by the top of his head and while rumpling his hair in a most 
uncomfortable manner, and digging their finger-tips into his 
scalp, ask him, solicitously, what he is going to " be" when he 
is a man. 

As has been said, this attention to the fundus is to be kept 



230 A NURSE'S HANDBOOK OF OBSTETRICS. 

up for one full hour after the birth of the child, by the end of 
which time the uterus will, in normal cases, have contracted 
firmly and permanently, and any further danger from hemor- 
rhage will be very remote. 

If, however, at the end of the hour the uterus is still relaxed 
and soft, and cannot be made to stay firmly contracted, the 
holding and kneading must be kept up until permanent contrac- 
tion takes place. If the delay is longer than two hours, it would 
be safer to notify the physician, even though the woman's gen- 
eral condition seemed to be good. 

As a rule, the physician prefers to attend to the fundus him- 
self for at least the first fifteen or twenty minutes, and this 
gives the nurse an opportunity to attend to the next most im- 
portant duty of the moment, which consists in " cleaning up" 
the bed and patient and making things as comfortable as possi- 
ble. The worst of the blood and discharges should first be 
washed off with a towel dipped in warm bichloride solution 
(1 to 1000). Next, the Kelly pad and everything under the 
patient are to be slipped out and into the pail at the side of the 
bed. A clean towel is now placed under the patient, a vulva 
pad applied temporarily, and she is covered with a clean sheet. 
The pail containing the Kelly pad and all soiled towels and other 
articles that may have been thrown in it or dropped on the floor 
is removed from the room, and already the most unpleasant fea- 
tures of the labor are out of sight. 

If the patient's night-gown has become soiled, it should be 
removed by cutting it down the middle in front and taking it 
off like a coat, for an attempt to bring it over the head will 
usually result most unpleasantly. If the patient objects par- 
ticularly to having it torn, it may be slipped off the shoulders, 
rolled down under the buttocks, and taken off over the feet, 
but the best and simplest plan is to tear it. As soon as it is 
removed a fresh warm one should be slipped over the head, on 
to the arms, and drawn down in front to cover the chest, but 
the back part of the garment is best left in a roll or soft pile 
under the shoulders or neck to avoid the possibility of its being 
soiled before the patient's back has been bathed. 



THE PATIENT'S TOILET. 



231 



In like manner, if there are any stains of blood or other 
matter on the stockings, they should be removed and fresh, 
warm ones put on. 

The nurse should now prepare a warm solution of Tinct- 
ure of green soap and, with fresh pieces of absorbent cot- 
ton carefully wash off any blood or other matter that may 
be on the abdomen or thighs, drying the parts immedi- 
ately with a clean, soft towel. When this is done, the pa- 
tient is carefully turned on one side and the process is repeated 
on the back, buttocks, and backs of the legs. It may be neces- 
sary to turn the patient first to one side and then to the other 
for this purpose, and as the towel under her will by this time 
be soaked with blood, it is to be removed and a clean one put 
in its place, as well as a clean pad over the vulva. 




f 



Fig. 114— Douc 



The patient is now returned to her back and preparations 
are made for cleansing the external genitals. Fresh green 
soap solution should be made up with warm boiled water, and 
the nurse is to disinfect her hands by scrubbing for five minutes 



232 A NURSE'S HANDBOOK OF OBSTETRICS. 

with soap and hot water and soaking for three minutes in bichlo- 
ride (i to 2000). 

If the patient is in good condition a sterile douche-pan (Fig. 
114), covered with a towel, should be placed under her, and the 
nurse should attend to this and to the preparation of her solu- 
tions and cotton sponges before beginning to disinfect her hands. 

When everything is ready the person holding the fundus 
will draw the covering sheet out of the way, and the patient is 
told to draw up her knees and separate them as far as possible. 
The hair covering the mons veneris and vulva will be found 
matted together with clotted blood, and if it is at all abundant 
the greater part should be carefully cut away with scissors. 
The parts are then to be bathed with the utmost gentleness with 
the warm solution until every vestige of blood is removed and 
the parts are perfectly clean. The douche-pan is now removed 
and a fresh vulva pad applied to take up the little stream of fresh 
blood that constantly trickles down over the perineum. 

If the patient has been confined on a cot, the next step is to 
remove her to her bed. The bed should be warmed, except, of 
course, in summer, and on the draw-sheet is to be laid one of 
the " obstetrical pads" from the maternity outfit. If the pa- 
tient is a large woman, and those who are to lift her are not 
very strong, it is better to move the cot up close to the side 
of the bed on which she is to lie; she may then be lifted up 
by two persons (usually the physician and nurse) standing side 
by side. As soon as she is raised from the cot, a third person 
draws it quickly out of the way and with one step forward her 
bearers place her gently in the bed and cover her with the bed- 
clothes. 

Unless the full hour after the birth of the child has elapsed 
she should not be moved except when the uterus is firmly con- 
tracted, and the fundus must be grasped again the moment she 
is laid down. During the brief interval required to change her 
from one bed to the other the unavoidable exertion to which 
she will be subjected will act as a sufficient stimulus to the uter- 
ine muscle to obviate the necessity of holding the fundus for a 
few seconds. • 



CARE OF INSTRUMENTS. 



233 



If she is to remain in the bed in which she was confined, the 
next step after cleansing the vulva is to unpin and remove the 
white sheet and rubber sheet on which she is lying, leaving the 
bedding underneath fresh and clean. At the instant this is done 
an obstetrical pad is to be slipped under her buttocks to protect 
the draw-sheet and avoid the necessity of changing it for as 
long a time as possible. 

If the full hour for holding the fundus has not yet elapsed, 
and the nurse is not occupied with this matter herself, she is 
to put the room in order, as quietly, thoroughly, and expedi- 
tiously as possible. All soiled articles, basins, pitchers, and the 
like, are to be removed ; towels, sheets, and other articles that 




Fig. 115. — Fountain syringe. 



are blood-stained are to be thrown into cold water, usually in 
the bath-tub with the water flowing in and out over them, until 
all stains are removed ; the physician's instruments are to be 
scrubbed with nail-brush, soap, and hot water, rinsed in fresh hot 
water, and dried thoroughly; and the furniture arranged prop- 
erly and with as little confusion as possible. The douche-bag 
(Fig. 115), if it belongs to the physician, is to be emptied, 
flushed out with hot water, and dried thoroughly, and the Kelly 
pad must be washed carefully with soap and hot water until it 
is absolutely clean, then rinsed quickly with scalding water and 



234 A NURSE'S HANDBOOK OF OBSTETRICS. 

dried. The air-ring must not be emptied nor the pad folded 
up until it is absolutely dry, or its opposed surfaces will stick 
together and ruin it. 

By this time there will usually be no further need of hold- 
ing the fundus, and the binder may be applied, so that the pa- 
tient may be left to herself and allowed to go to sleep. 

The function of the binder is often misunderstood by the 
laity, who are apt to suppose that it is used for the purpose of 
preserving the symmetry of the figure by preventing the lax 
abdominal walls from bulging outward. This is far from the 
truth, and in France, where women are supposed to be particu- 
larly solicitous as to their physical appearance, the obstetrical 
binder is not used at all. 

The objects of the binder are two : first, to prevent any 
tendency to hemorrhage by keeping up a firm and constant press- 
ure over the uterus ; second, to make the woman comfortable 
by preventing cerebral anaemia, with its accompanying dizziness, 
headache, and, in some cases, even syncope. 

The causation of anaemia of the brain after labor will readily 
be understood when it is remembered that the walls, not only of 
the abdomen but of the abdominal blood-vessels, are lax and 
flabby after the comparatively sudden emptying of the cavity 
and the accompanying loss of from one to two pints of blood. 
To fill these empty vessels blood comes rushing in from other 
parts of the body, and unless they are subjected to the firm 
pressure of the binder, so much blood will be abstracted from 
other organs and tissues that the result, while not neces- 
sarily serious, is bound to be more or less uncomfortable to the 
patient. 

After about three days, when the balance of blood-pressure 
has again become established and the possibility of hemorrhage 
is past, the binder is no longer necessary, although the patient 
usually finds it very comfortable to wear it for a week or so 
more, and then, in many cases, to substitute for it an abdominal 
supporter (Fig. 116), which she continues to wear for another 
month, or until involution is complete. 

Acting on these principles, the author always insists on the 



THE ABDOMINAL BINDER. 235 

use of the binder for the first three days. After this he allows 
the patient to decide for herself whether she wishes it used or 
not. 

The binder should be made of unbleached muslin, one and 
three-quarters yards long and three-quarters yard wide. The sel- 
vage may be torn off and the winder washed and ironed to make 
it soft and comfortable. Not less than six should be provided, so 




Fig. 116. — Teufel's abdominal supporter. 



that soiled ones may be changed as often as necessary. Binders 
should not be hemmed, as the hem is apt to cause unpleasant 
pressure, but the edges may be " overcast" if desired. Binders 
of any other dimensions than those given are not desirable, and 
those made of two thicknesses of cloth or in any way " fitted" 
to the body are very impracticable. In an emergency an excellent 
binder can be made of a piece of " roller" towelling cut the proper 
length. 

In applying the binder its purpose must be kept in mind 
and never overshadowed by efforts to gain an artistic effect in 
the arrangement of the pins. This is a common fault in the 
training that nurses receive in the wards, for not only is the 
strength and good-nature of the private patient often exhausted 
by delay and fussiness in pinning up a binder, but the binder 
itself is seldom as snug at every point as it should be. 

The binder should be folded about half its length and slipped 
under the patient in the same way that a draw-sheet is changed. 
The ends are then held up in the air over the middle of the 
abdomen and the binder drawn in one direction or the other 



236 A NURSE'S HANDBOOK OF OBSTETRICS. 






Fig. 117. — Abdominal binder. 



THE ABDOMINAL BINDER. 



237 



until its middle is exactly under the middle of the patient's back, 
its lower edge well below the hips, and its upper edge at about 
the free border of the ribs. Beginning now at the lower edge, 
the two ends, held tightly together, are rolled up as firmly and 
as snugly as possible until the material at that point is as taut 
as it can be made. The pin is passed first through the roll and 
then through the single thickness of cloth on the side opposite 
the nurse and clasped. Beginning again a little above the first 
pin the rolling is repeated in the same way and another pin 
inserted, and so on till all is done (Fig. 117). 

When at a point about the level of the umbilicus, a towel, 
rolled or folded to about the size of a large banana, may be laid 
crosswise of the abdomen under the binder, to cause extra press- 
ure on the fundus. A pin should be passed through the binder 
into the towel on either side to keep it from slipping. 

The binder must be changed with sufficient frequency to 
keep it clean and comfortable at all times, and during the first 
two days this should be done as often as every four or five 
hours. Blood trickles down over the perineum and soaks into 
the binder behind, soon drying and becoming stiff and irritating, 
so that, no matter how clean and soft the front of the binder 
may be, frequent changes are none the less necessary. When 
the soiled binder has been removed the patient should be turned 
on her side and the buttocks bathed gently with soap and warm 
water and rubbed with dilute alcohol. The amount of comfort 
that this affords the patient well repays the slight trouble that 
it entails. Soiled binders are to be washed immediately after 
they are removed, and boiled and ironed before they are used 
again. 

The vulva pads must be changed at intervals of not less than 
every four hours, and, for the first day or two, fresh ones may 
be required as often as every one or two hours. If, for any 
reason, an apparently clean pad is taken off, it is never to be 
replaced, but a new one used in its stead. The reason for this 
absolute rule is because of the possibility of placing over the 
vulva that part of the pad which formerly was in direct con- 
tact with the anus. Soiled pads must be removed at once from 



238 A NURSE'S HANDBOOK OF OBSTETRICS. 

the room and destroyed by burning. Under no circumstances 
should a pad be washed or otherwise cleaned (?) and used 
a second time. 

Every time a pad is removed the external genitals are to 
be bathed carefully and gently with warm green soap solution 
made up with boiled water. The nurse is to disinfect her hands 
for this purpose, bestowing on them as much care as though she 
were going to make a vaginal examination. Before the hands 
are disinfected the pad is to be unpinned and left loosely in 
position and a piece of paper laid on the floor to receive it. The 
dish containing the solution and cotton sponges is placed on a 
chair or on the bed within easy reach, and the parcel of clean 
pads is opened and laid in a convenient spot. 

After the hands are clean the soiled pad is removed with a 
thumb-forceps and laid quickly on the paper, out of sight of 
the patient, to whom its appearance is usually very unpleasant. 
The cleansing of the parts should begin with the separation of 
the labia majora with the thumb and forefinger of the left hand 
and the careful removal of any lochial discharge that may have 
accumulated in the creases of the vulva. This blood is always 
more or less irritating and tends to become dry in spots, which 
adds to the discomfort that it causes. In spite of this, the 
patient often refrains from speaking of it, on account of her 
natural disinclination to require of the nurse duties which she 
knows must be of a somewhat repellant character. The nurse 
who will attend carefully to this little detail will find her efforts 
more highly appreciated than would seem to be warranted by the 
circumstance. 

After this has been done the external surfaces of the labia 
are carefully bathed from above downward, care being taken 
to remove every vestige of blood from the hair. If stitches have 
been inserted in the perineum the nurse must take pains not to 
let the cotton catch and pull on the free ends of the sutures, or 
she will cause the patient great pain. 

If any blood has collected on the buttocks and soaked into 
the back of the binder these parts must be made perfectly clean 
and the binder changed, as has already been said. 



THE CARE OF THE BED. 239 

The pads and draw-sheet under the patient must be removed 
as often as they become soiled, but if the nurse is particular to 
change the pads frequently or to keep folded sterile towels over 
them, the draw-sheet will last for an entire day or possibly a 
little longer. As a rule, the draw-sheet is to be changed every 
twenty-four hours, and clean vulva pads must be provided 
at least as often as every four hours, and oftener if they are 
much stained, for even when they do not appear to be par- 
ticularly soiled they always contain, after a few hours, 
enough of the lochia to serve as an excellent breeding-place 
for bacteria. 

If the patient does not void her urine naturally within twelve 
hours after labor the bladder should be emptied with the cath- 
eter, and after this she is to be catheterized every six hours until 
the normal function of urination is re-established. 

Twelve hours is allowed in the first instance, because the 
relaxed condition of the bladder and abdomen after the removal 
of the pressure from the gravid uterus often permits consider- 
able distention of the bladder with urine before any desire to 
urinate manifests itself. Every effort should be made to avoid 
the use of the catheter, because of the danger of infecting the 
parts at the time of its introduction, and also on account of the 
fact that its use always tends to delay the time when natural uri- 
nation can be accomplished. Moreover, if the patient can once 
be induced to empty her bladder in the normal way, the subse- 
quent use of the catheter is almost never required. Conse- 
quently, at the end of the first twelve hours, and thereafter at 
intervals of six hours, efforts should be made to excite normal 
urination by the familiar methods of allowing water to run from 
a faucet, pouring water from one pitcher to another, directing 
a gentle stream of warm sterile water down over the vulva, or 
placing under the patient a bed-pan containing hot water and 
letting the steam from it surround the genitals. With some 
patients the mere presence of a second person in the room is 
enough to prevent urination, a*id, in such cases, the nurse should 
always leave the room on some pretext or other as soon as she 
has arranged the bed-pan, taking pains to tell the patient that 



2 4 o A NURSE'S HANDBOOK OF OBSTETRICS. 

she will not be back for a few minutes. Not infrequently, on her 
return she will find the bed-pan ready for removal. 

If, however, all these efforts fail after a reasonable trial, the 
catheter must be used. This is an operation requiring great 
dexterity in the case of a woman recently delivered, for the 
parts are swollen and congested to such a degree that all the 
usual landmarks are distorted or temporarily destroyed. On 
several occasions the writer has been called upon to pass the 
catheter in the first day of the puerperium after nurses of long 
obstetric experience have failed utterly to find the meatus. The 
best catheter for the purpose in hand is the ordinary glass one 
(Fig. 118), about six inches long and slightly bent at the tip. 



^ 



Fig. 118. — Glass catheter. 



The soft rubber catheter, so often used in the belief that it is 
less liable to injure the delicate tissues of the parts, is not 
worth considering, for it possesses no advantages over the glass 
instrument and is inserted with much greater difficulty. 

The preparations for using the catheter in private practice, 
where there is usually only one nurse on the case, are important, 
and must be carried out in detail to avoid the danger of infecting 
the patient. 

The catheter is to be boiled and the urine should be received 
in the basin used for boiling the instrument, or in a douche-pan, 
but never in a urinal which has to be placed in position after 
the nurse's hands are sterilized. 

The simplest, and therefore the best, method is as follows : 
Boil the catheter in an agate basin of sufficient size to hold all 
the urine to be drawn off and with only enough water to cover 
the instrument. Prepare Tincture of green soap solution and cot- 
ton sponges, and have a clean vulva pad within reach. Place a 
piece of paper on the floor to receive the soiled pad. As a lubri- 
cant for the catheter use white vaseline (in a tube) or, what 
is still better, any one of the preparations of Iceland moss lubri- 



THE USE OF THE CATHETER. 



241 



cants which may be had of almost any druggist. Remove 
the screw-top and wrap the tube in sterile or bichloride gauze. 
Disinfect the hands, as before, with soap and hot water and 
bichloride solution, and after the patient has raised her knees 
and separated them as far as possible, take up the basin con- 
taining the catheter with a wet bichloride towel, pour off as 
much water as possible without spilling out the catheter and 
set the basin in the bed as close up to the vulva as possible. 
Remove the vulva pad with thumb-forceps and cleanse the .parts 
thoroughly. Then take up the catheter, which by this time is 
sufficiently cool, squeeze on it some of the vaseline or other 
lubricant, and lay it back in the basin out of the water. (The 
basin can be tilted somewhat so that part of its bottom will be 




Fig. 119. 



-Proper method of inserting catheter. The labia separated and the meatus 
exposed to view. 



dry.) Now separate the labia as far as possible with the thumb 
and fingers of the left hand, until the opening of the meatus 
can be seen. Wipe off the tissues surrounding the urethral 
orifice with a clean cotton sponge dipped in the solution and, 
with the left hand still keeping the labia widely apart, pick up 
the catheter with the other and pass it, by the sense of sight, 
directly through the meatus into the bladder, taking every pre- 
caution not to let it touch any of the surrounding parts (Fig. 
119). 

The basin, if properly placed, will be near enough to the 
vulva to receive the stream of urine without any difficulty. 

16 



242 A NURSE'S HANDBOOK OF OBSTETRICS. 

When the bladder is empty, grasp the catheter between the 
thumb and second finger and press the forefinger firmly over 
the tip before withdrawing it (Fig. 120). When it is entirely 
out and over the basin the forefinger may be raised, and the 
urine within the tube will escape. This is a small matter of 
detail but will often save soiling the bedding or the patient's 
el thing. 

As has been said, every effort should be made to avoid the 
use of the catheter, and after the third day the patient may be 
allowed to sit up in bed to empty the bladder if the case is pro- 
gressing favorably. This, of course, should only be done with 
the consent of the physician, and the nurse should make sure 
that no ill effects follow the exertion. 





Fig. 120.— Method of withdrawing catheter. 

The patient's bowels should have been emptied by enema at 
the beginning of labor, and will not, as a rule, require any 
attention until the end of the second day. At this time the 
physician usually orders a mild saline laxative, such as one- 
half of a bottle of the effervescent solution of the citrate of 
magnesia, at night, followed by the other half in the morning. 

If this is not successful, a soapsuds enema may be given in 
the middle of the forenoon, after waiting a reasonable time for 
the magnesia to act. If the progress of the case up to this 
time has been perfectly normal, there is usually no objection to 
letting the patient sit up on the bed-pan to empty the bowels, 
and if this can be allowed the enema is seldom required. 



THE VAGINAL DOUCHE. 



243 



After this the bowels are to be moved every second day by 
enema or otherwise, as the physician may direct, unless the 
natural efforts are effectual. 

While the patient is on the bed-pan she is to be directed to 
hold the vulva-pad closely against the vulva with her hand to 
prevent the entrance of fecal matter into the genital canal, and 
the nurse, in cleansing the parts, must be careful to wipe from 
before backward (from the vulva toward the sacrum). 

It is needless to say that no vaginal douche should ever be 
given by the nurse except in compliance with the express direc- 
tions of the physician. If the lochial discharge emits a foul 
odor the physician may order a douche, but the matter must be 
left entirely with him. 

Before giving a douche the nurse must disinfect her hands 
with the utmost care by scrubbing them thoroughly with soap 
and hot water changing the water at frequent intervals, and 
then soaking them in hot bichloride solution ( 1 to 2000). The 
douche-bag and nozzle must be boiled before use, and the solu- 
tion used for douching is to be made of boiled water. The 
douche-bag should hang about four feet above the level of the 
patient's bed, and the woman is to lie on a bed-pan covered 
with a sterile towel. 

The greatest care must be taken, in inserting the nozzle, that 
it does not come in contact with the external surface of the body 
or with the hair covering the genital organs. The nurse should 
hold the douche-tube in her left hand, and with the fingers of 
the right separate the labia as far as possible so that the entrance 
to the vagina is clearly in sight (Fig. 121). The tube can now 
be introduced into the genital canal without touching any of 
the external tissues, and the danger of carrying infection into 
the vagina is effectually eliminated. The physician will, of 
course, instruct the nurse as to the solution to be used for the 
douche and its temperature, but in the absence of any definite 
directions, as, for example, when he merely leaves word to the 
nurse while she is out that the patient is to be douched, she may 
safely use two quarts of normal salt solution (two drachms to 
the quart) at a temperature of no° F. 



244 A NURSE'S HANDBOOK OF OBSTETRICS. 

The temperature and pulse of both mother and child are 
to be taken every four hours during the first week and after- 
wards every night and morning unless the case is not doing 
well, when the four-hour record is to be continued. The tem- 
peratures of both patients are to be recorded on separate charts, 
to facilitate a clear understanding of the entire record at one 
glance. 

The public is so well educated in the matter of clinical ther- 
mometry that these charts must be kept out of sight of the 
mother from the very first, so that in the event of any unex- 




Fig. 121. — Proper method of introducing douche tube. 

pected complication she will be ignorant of the amount of her 
fever and unsuspicious at the withdrawal of the chart from her 
daily inspection. 

A pulse of ioo or a temperature of 100.5 F. is to be re- 
ported to the physician without delay, as either may indicate 
the onset of some serious disorder. 

Every attention must be paid to the comfort of the patient, 
for the more nearly normal her case, the more tedious is her 
confinement in bed while awaiting the involution of the uterus 



DIET IX THE PUERPERIUM. 



245 



and other generative organs. She should be moved from one 
side of the bed to the other several times a day, and required to 
turn frequently from side to side after the first twenty-four 
hours. Her personal toilet must never be neglected to the slight- 
est degree, and her face and hands should be washed and her 
teeth brushed several times daily. Her hair is to be well brushed 
and combed night and morning, and this is most easily managed 
bv doing it up in two braids, so that there will be no mass of 
hair directly at the back of the head. A warm general sponge 
bath with a little soap is to be given once daily, and this is of 
especial importance on account of the excessive perspiration that 
occurs during the puerperium. This bath is best given at night, 
just before the patient is ready to go to sleep, and but one part 
of the body should be exposed at a time. After the bath the 
entire body is to be rubbed with alcohol and water (equal parts), 
or, on account of the peculiar odor of the lochia, which is often 
quite distasteful to the patient, cologne or some favorite toilet- 
water may be used in place of the alcohol. It need not be said 
that the use of cologne or toilet-zvater must never be allowed to 
cover any laxity in the attention paid to the patient's toilet. 

The nurse must be quick to anticipate any and every need 
of the patient in the matter of her personal comfort, and never, 
under any circumstances, make it necessary for her to ask for 
attentions of this nature that should have been performed as a 
matter of course. 

The diet during the puerperium must be of a simple char- 
acter, but nourishing and sufficiently varied to please the appe- 
tite of the patient. In ordinary cases the following dietary will 
be all that is needed. 

First forty-eight hours: Milk (one and one-half to two 
pints a day), gruel, soup, one cup of tea a day, toast and butter. 

Second forty-eight hours : Milk-toast, poached eggs, por- 
ridge, soup, corn-starch, tapioca, wine- jelly, small raw or stewed 
oysters, one cup of tea or coffee a day. 

Third forty-eight hours : Soup, white meat of fowl, 
mashed potatoes, beets in addition to the above. 

After the sixth day return cautiously to ordinary light 



246 A NURSE'S HANDBOOK OF OBSTETRICS. 

diet ; that is, three meals a day, meat of an easily digested char- 
acter at one of them, such as white meat of fowl, tenderloin of 
beef, etc. Also a glass of milk three times a day, between meals 
and before going to sleep at night, and a glass in the middle of 
the night. 

Visitors should be excluded as far as possible during the 
first two weeks of the puerperium, and, as a rule, none but 
members of the immediate family should be admitted, and these 
for not more than five or ten minutes at a time. Friends and 
distant relatives are usually more interested in the baby than 
in the mother, and the infant prodigy may be exhibited for a 
brief interval to such callers in another room. The practice, 
common even among the better classes, of turning the lying-in 
chamber into a general meeting-place for conversation and gossip 
must be distinctly forbidden by the nurse. 

Flowers, so often sent in great profusion to the puerperal 
woman, may be shown to her as an evidence of the interest of her 
friends, but should be banished at once to the parlor or dining- 
room. A few flowers of faint and delicate odor may be placed 
at the side of the bed or on a table within her sight, but large 
bouquets of much fragrance are too overpowering for the good 
of the patient. 

The room is to be aired freely and with sufficient frequency 
each day to keep it fresh and sweet, for the lochia, the milk, the 
discharges of the infant, and the perspiration of the mother all 
tend to vitiate the atmosphere to a marked degree. In cold 
weather the patient is to be entirely covered with a sheet and 
blanket reaching above her head while the windows are opened 
for the purpose of ventilation. 

If the arrangement of the house permits, the nurse should 
always sleep in an adjoining room, to which she can take the 
baby for the night, and in which, in fact, the infant should spend 
the greater pari of its time. Under no circumstances should 
the nurse ever sleep with the patient, and if another room is not 
available she should be provided with a separate bed or cot. 

Unless the nurse is a very light sleeper, the patient should 
be given a small bell with which to call her when she is needed. 



TIME SPENT IN BED. 



247 



The directions for the care of the infant and the management 
of its feeding are discussed elsewhere, and must be followed 
implicitly, and the nurse must keep a sharp watch for soreness 
or erosions of the nipples and report their occurrence at once 
to the physician. 

The time when the patient can get out of bed, or sit up 
in bed, is a question that always causes her great concern, and 
the nurse will do best to make no positive statement in this con- 
nection even in the most favorable cases. Physicians no longer 
observe any arbitrary rule in keeping a puerperal woman in bed, 
and each case must be decided on its own merits. 

As a rule, permission to sit up is granted when involution 
has progressed to such a point that the fundus uteri can no 
longer be felt above the symphysis pubis. Even this cannot 
always be depended upon, and many factors may have to be 
considered before a definite conclusion is reached. 

Generally speaking, women of the class likely to come under 
the care of the graduate nurse are required to spend two weeks 
in bed, one week on a couch or on the bed, gradually accustoming 
themselves to the use of an arm-chair, and one week up and 
about but confined to the same floor. After the fourth week 
the patient may begin to go up and down stairs slowly once or 
twice daily, but six weeks in all should elapse after the birth 
of her child before she can regard herself as entirely freed from 
all restraint. The fact should be impressed upon her that this 
protracted period of non-exertion is not required because she 
is, in any sense, an invalid, but in order to permit involution 
to go on uninterruptedly. The idea is much the same as that 
which would hold in the case of a broken leg, where rest would 
be absolutely essential to perfect recovery, although the patient's 
general condition would be in no way affected. 



XX 

The Disorders of the Puerperium 

The disorders of the puerperium are : puerperal fever, in 
its various forms ; phlegmasia alba dolens, or " milk leg;" dis- 
eases of the nipples and breasts; and insanity. 

Puerperal fever, also known as puerperal septicemia and 
" child-bed fever," is a condition always due to infection from 
without, and this infection may, and usually does, result from 
the introduction of bacteria into the genital tract at the time of 
the labor, either by the hands or instruments of the physician, 
or, after labor, by surgical uncleanliness on the part of the nurse, 
whether in the use of the catheter or in her general care of the 
patient. In rare instances the infection may be due to a septic 
inflammation of the vagina or other pelvic organs which exists 
at the time of the labor and extends to the interior of the uterus 
or to other tissues after the birth of the child. 

The usual point of entrance for the septic germs is at the 
denuded placental site in the uterus where the tissue is " raw," 
and bacteria can easily find a way into the system, but any other 
raw surface, such as a laceration of the cervix or perineum, may 
afford an equally good starting-point for the disease. 

There are several varieties of puerperal fever, each of which, 
in its typical form, presents a very characteristic set of symp- 
toms, but it not infrequently happens that one form of the dis- 
ease will eventually develop into another and more severe kind. 
The distinctions between these different types are, of course, of 
interest and importance to the physician, for not only the treat- 
ment but the prognosis depends upon the particular form of 
infection from which the patient suffers. 

As far as the nurse is concerned, however, it is only neces- 
sary to be able to recognize at once the onset of the disease in 
order that the physician may be notified immediately and proper 
treatment instituted without delay. 
248 



PUERPERAL FEVER. 249 

Puerperal fever usually develops about the third or fourth 
day after delivery, but its onset may be postponed until the 
eighth, ninth, or even tenth day. As a rule, however, if there 
are no symptoms by the end of the first week none will appear 
at any time. Tht ^ases that develop after this period are rare, 
are often due to infection introduced by the catheter or other- 
wise several days after delivery, and are seldom of sufficient 
severity to endanger the patient's life, although they may seri- 
ously affect her general health for months or even years. 

The patient first complains of malaise, headache, backache, 
and general discomfort. This is soon followed by a distinct 
chill, or, occasionally, only by chilly sensations, and the ther- 
mometer shows a considerable rise of temperature, often as high 
as 105 or 106 F. In the severe cases the pulse becomes rapid 
and feeble and may be irregular, and the patient's face is pale 
and anxious. The tongue is at first heavily coated, but later 
becomes brown and dry, and the lips are covered with sordes. 
The lochial discharge stops, or it may become dark and very 
offensive. The abdomen is soft and usually slightly tender over 
the uterus, but there is no actual pain or tympanites unless 
general peritonitis develops as a complication. Vomiting may 
or may not occur, and severe diarrhoea is very common. The 
urine is scanty, high colored, and may contain albumin, and if 
the secretion of milk has begun it ceases. The patient has alter- 
nating delirium and stupor, followed by coma, and death may 
occur within a few days. 

These symptoms belong to the most severe type of puerperal 
fever, in which the infection, beginning in the uterus, extends 
rapidly throughout the entire system. In the milder cases, where 
the infection is less virulent, or where it is confined to the 
uterus itself or to lacerated tissue in the cervix, vagina, or 
perineum, the symptoms are not so pronounced, and the patient 
usually recovers, although she may be transformed into a con- 
firmed invalid or, at least, remain sterile the rest of her life. 

The treatment, of course, rests entirely with the physician, 
and usually consists in the thorough exploration of the interior 
of the uterus and the removal of any placental tissue, clots, or 



250 A NURSE'S HANDBOOK OF OBSTETRICS. 

other foreign matter that may be present and undergoing decom- 
position. This is, in many cases, all that is required, and the 
careful emptying and douching of the uterine cavity is followed 
by an immediate fall in temperature and improvement in every 
way. More often, however, it is thought necessary to perform a 
thorough curettage under ether in order to remove every par- 
ticle of infected tissue from the uterine wall, and not a few 
physicians adopt this method at the outset rather than take any 
chances with less radical treatment. 

As the prompt institution of measures to check the disease 
is of the greatest importance, the nurse must always be on the 
alert to recognize any one of the initial symptoms of puerperal 
fever the moment it appears and report it at once to the physi- 
cian. Headache, backache, malaise, or any feeling of discom- 
fort must not be overlooked, and a rise of temperature over 
100.5 ° F. or of pulse over 100 should be brought to the physi- 
cian's notice without delay. 

These premonitory symptoms may not indicate puerperal 
fever, as they occur at the onset of almost any acute disease, but 
they are sufficiently significant to warrant immediate attention, 
and the nurse must never lay herself open to the charge of hav- 
ing neglected to recognize, and report to the physician in charge, 
any change in the patient's condition which might be indicative 
of danger. 

After the genital tract has been thoroughly cleansed of all 
foreign matter the treatment consists solely in fighting the 
constitutional effects of the disease with tonics, stimulants, and 
nourishing diet. Crede's ointment (unguentum Crede), a 
preparation of metallic silver used by inunction, has been highly 
recommended as a specific by some authorities ; the subcutaneous 
injection of hot normal salt solution often seems to give good 
results ; and, in those cases due to infection by the streptococcus, 
the antistreptococcic serum (streptococcus antitoxin) has been 
administered hypodermically with alleged benefit; but none of 
these methods has the unqualified approval of all physicians, and 
success can only be expected to follow a judicious combination 
of several of the recognized means of fighting the disease. 



"MILK LEG." 



251 



Phlegmasia alba dolens ("milk leg") is a disease of the 
puerperium characterized by pain and swelling in the affected 
limb due to the formation of a clot in the veins of the leg itself 
or in those of the pelvis, interfering with the return circulation 
of blood. It is due to septic infection extending from the uterus 
to the veins of the pelvis, and thence down the leg, and usually 
appears about two weeks after labor, the most common time 
being on the eleventh or twelfth day. 

The disease is ushered in with malaise, chilliness, and fever, 
which are soon followed by stiffness in the affected leg and pain, 
usually in the groin. The leg now begins to swell, either from 
above downward or from below upward, and in a few hours 
is so tense and exquisitely painful that the slightest movement 
causes intense suffering. 

The acute symptoms last a few days or a week, after which 
the pain gradually subsides and the patient slowly recovers. 

The course of the disease covers a period of from four to six 
weeks, and the affected leg seldom returns to its normal size, but 
remains permanently enlarged. 

The prognosis is usually favorable, although in some of the 
very severe cases abscesses form and the disease may become 
very critical or even prove fatal, while in very rare instances the 
clot may be dislodged and carried to the heart, causing instant 
death. 

The treatment consists in absolute rest, the use of ice-bags 
along the course of the affected vessels, and morphine as indi- 
cated for the pain. As the acute stage subsides, general tonics, 
nourishing food, and the most carefully regulated hygienic con- 
ditions are needed to build up the patient's strength. 

As in all acute febrile diseases occurring after labor the 
secretion of milk ceases when phlegmasia alba dolens is devel- 
oped, and the physicians of many years ago gave to the disease 
the name of " milk leg," in the absurd belief that the condition 
was due to a secretion and collection of milk in the affected 
limb. So firmly was this impossible idea fixed in the minds of 
womankind, that to this day the expression " milk leg" is in 
common use among the laity. 



252 A NURSE'S HANDBOOK OF OBSTETRICS. 

Diseases of the nipples and breasts. Any slight erosion 
of the nipple may be aggravated by nursing until an actual fis- 
sure is formed. The fissure will cause great pain at each nursing 
period, and the pain may be enough to absolutely prevent suck- 
ling at the affected breast. This may cause congestion of the 
gland, and, as the surface of the fissure offers an ideal entrance 
for bacteria, septic inflammation or abscess of the breast may 
result. Even when septic infection does not occur, the pain may 
seriously affect the secretion of milk and, in highly nervous or 
hysterical women, cause a slight rise of temperature and retard 
involution of the uterus and its adnexa. 

If nursing is impossible the child is deprived of its proper 
food, while if nursing is continued in spite of the pain the pro- 
teids of the milk are apt to be increased, and the discharge from 
the eroded surface is extremely bad for the baby. Hence it will 
be seen that this condition, trivial though it may appear at first 
thought, exerts a most harmful influence on both mother and 
child. 

The first symptom of erosion or fissure of the nipple is pain 
at the time of nursing, and careful inspection of the part will 
at once disclose the true nature of the trouble. 

The treatment includes the preventive measures to be adopted 
during the last two or three months of pregnancy. These, 
already discussed in Chapter IX., consist in bathing the breasts 
night and morning with cold water, and softening the crusts of 
colostrum with albolene, and removing them every day, so that 
the delicate tissue of the nipple will not be injured by the 
presence of these hard deposits. If these precautions are care- 
fully followed the nipples will be in good condition when the 
infant begins to nurse, and no trouble will be likely to ensue. 

The treatment after the condition has developed rests with 
the physician, and the nurse should report to him at once if the 
nursing is painful or if any eroded surfaces are noticed. The 
usual treatment consists in cleansing the parts thoroughly and 
applying a solution of nitrate of silver (forty grains to one 
ounce) with a fine camel's-hair brush to the diseased surfaces, 
after which the nipple is dusted with some simple antiseptic 



MASSAGE OF THE BREAST. 253 

powder, such as aristol, and nursing stopped on the affected 
side for twenty-four hours. 

A considerable quantity of milk will collect in the breast 
during the time in which nursing is stopped, and this must be 
removed with the breast-pump or by massage as often as the 
gland becomes tense and tender. The method of using the breast - 
pump is described in detail on page 295. Massage of the 
breast when merely for the purpose of removing an excessive 
quantity of milk is a far simpler procedure than when inflam- 
mation has actually begun, and is performed as follows : There 
are four distinct steps in the emptying of the breast, each of 
which must be practised carefully and intelligently in order to 
secure a good result with the least amount of pain. The breast 
is first cleansed gently with soap and warm water, and then 
anointed with warm camphorated oil or albolene. The hands 
of the nurse must also be disinfected with the utmost care and 
the fingers dipped in the oil or other lubricant to be used. 

The first step (Fig. 122, A) consists in grasping the breast at 
its periphery with the fingers separated as widely as possible, 
and then drawing them towards the nipple with a firm but 
gentle pressure. The entire breast is to be gone over in this 
manner and the fingers are to be brought together as the nipple 
is approached, and this manoeuvre is to be kept up for at least 
five minutes, by the end of which time the breast should be 
fairly soft and the milk flowing freely. 

The second step (Fig. 122, B) consists in placing one hand, 
palm upward, under any indurated or " caked" portion of the 
breast, and with the fingers of the other pressing downward 
towards the supporting hand and forward towards the nipple. 
Each indurated spot is to be treated in turn in the same man- 
ner until all are soft. 

The third step (Fig. 122, C) consists in pressing downward 
against the chest wall with the flat of the hand over any hard- 
ened areas that may remain. The pressure should be greatest 
on the side of the hand next to the periphery of the breast, and 
should gradually increase towards the nipple with a sort of 
rocking motion. This is followed by a rotary motion of the 



254 A NURSE'S HANDBOOK OF OBSTETRICS. 

palm of the hand over the induration, continued until no further 
softening can be accomplished. 

The fourth step (Fig. 122, D) consists in grasping the entire 
breast in both hands and squeezing out whatever milk remains. 

Massage of the breast must always be practised with the 
utmost gentleness, for fear of injuring the delicate structures of 
the gland, and, in the manner described, it should never be 
especially painful if it is properly performed. Any roughness 
in the manipulations may cause damage to the tissues and result 
in the formation of an abscess. 

In applying the nitrate of silver solution to the fissure the 
nurse must separate the edges as widely as possible and touch 
only the denuded tissue of the fissure with the tip of the brush. 
Carelessness in the use of the solution not only smears the breast 
with a black, dirty-looking stain, but also causes more or less 
irritation to the surrounding parts. 

When the fissure does not heal sufficiently by the end of 
twenty-four hours to permit of painless nursing it may be neces- 
sary to use a nipple shield for a few days, and this will always 
be the case when both breasts are affected at the same time, 
unless the child is given artificial food while the process of 
repair is going on. The shield (Fig. 123) must be made scrupu- 
lously clean immediately before and after each nursing, and is 
to be boiled once daily. It must be applied to the nipple with 
the utmost gentleness, and before the child is allowed to nurse 
enough milk to fill the glass part of the shield must be ex- 
pressed into it by massaging the breast for a few moments. If 
this is neglected the infant will get little or no milk at all, while, 
on the other hand, he will suck in a quantity of air which will 
distend his stomach and cause colic. 

The nipple shield must never be placed on the breast in 
such a position that when suction begins the edges of the fissure 
will be drawn apart, and in certain cases, such as fissure at the 
base of the nipple, it will do more harm than good. 

The shield is always to be used with the greatest caution, 
and must at all times be kept in a perfectly aseptic condition. 
As the majority of fissures will, under proper treatment, heal 




Fig. 122.— Massage of the breast. 



INFLAMMATION OF THE BREAST. 



255 



completely in twenty-four hours, it seldom happens that the use 
of the shield is necessary, and when, for any reason, it must 
be employed, it should be laid aside the moment that it can be 
dispensed with. 

If the nipples are in a healthy condition the mother should 
never be allowed to use the shield merely to avoid the discomfort 
caused by the suckling of a vigorous child. 

Mastitis (inflammation of the breast) may be of any grade, 
from a simple congestion to a suppurative process that results 
in the formation of multiple abscesses in the glandular tissue. 







Fig. 123. — Nipple shield. Best kind. 



The cases of simple congestion may be due merely to over-secre- 
tion of milk and consequent distention and congestion of the 
mammary gland, but those accompanied by suppuration are 
always due to septic infection which enters usually through a 
denuded or diseased nipple. 

There are four periods when mastitis is especially liable to 
occur, but it may make its appearance at any time during lac- 
tation. The periods of greatest frequency are during the first 
month, and especially the first fortnight after birth, when the 
nipples are tender and not accustomed to nursing; whenever 
nursing is suddenly stopped (as, for example, on account of 
the death of the child) and the breast becomes engorged with 
milk ; at the time when the infant cuts its teeth and the nipples 



256 A NURSE'S HANDBOOK OF OBSTETRICS. 

are again exposed to injury ; and at the end of lactation, either 
because of hypersecretion of milk due to careless management 
when the infant is weaned, or because the child, being dissatis- 
fied with the quality or quantity of the milk, shows its dis- 
pleasure by biting or gnawing the nipple until it is injured and 
sore. 

The first symptoms of mastitis are a feeling of discomfort 
and pain in the breast, followed by chilliness or a distinct chill 
and a sharp rise of temperature to 105 ° or 106 F. Inspection 
shows that the gland is tense, hard, nodular, red, and exquisitely 
painful. 

If treatment is begun at once, it may be, and often is, possible 
to check the disease at the outset, but to accomplish this result 
energetic measures must be resorted to without delay. 

The physician must be notified immediately, and if there 
promises to be a wait of several hours before his presence or 
his advice can be secured the nurse may properly proceed to 
empty the breast, empty the bowels, and apply an ice-bag. 

The breast is to be emptied by massage combined, if neces- 
sary, with the use of the breast-pump, and all the milk that can 
be extracted is to be removed. 

A snug breast-binder (Fig. 124) is now applied and, after 
it is pinned, holes about the size of a half-dollar are cut over 
each nipple to allow the milk to escape. This can be done by 
picking up the material directly over the nipple with a thumb- 
forceps, drawing it well away from the body, and cutting through 
it with scissors, after which the opening is carefully enlarged to 
its proper size and shape. If a piece of cotton is laid over each 
nipple before the binder is applied, there will be no difficulty 
whatever about grasping the muslin, and after the hole is cut 
the cotton may be left until it is soaked with milk, when it is to 
be removed and fresh pieces inserted. An ice-bag is now placed 
over the inflamed area and left until all inflammation has sub- 
sided or until the physician orders its removal. The bowels are 
best moved with a saline cathartic, such as sulphate of magnesia 
(Epsom salt), one-half ounce in half a glass of water. 

Nursing must, of course, be stopped at the affected breast. 







Fig. 124. — Author's breast-binder. 



THE BREAST-BINDER. 



257 



5 S 4 S € 7 & § fp 



K17 18 19 




a 9 Jo ?J ft 1$ M JS fir /? 18 ty 



Fig. 125.— Pattern of author's breast-binder. 
17 



258 A NURSE'S HANDBOOK OF OBSTETRICS. 

and the ingestion of fluids is to be restricted as much as possible 
until all the symptoms have disappeared. 

This treatment, if begun at once, is usually successful in 
checking the disease, but, as has been said, it must be instituted 
without a moment's delay if it is to be effective. 

If it is unsuccessful and the case goes on to suppuration, 
the treatment is necessarily surgical, and the nurse can only 
follow the directions of the medical attendant. 

It may be said that the cases of mastitis that develop during 
the first month after labor seldom go on to suppuration, but 
those appearing later in the puerperium are very likely to do 
so unless they can be checked in the manner described. 

Syphilitic lesions may be found on the nipple, either primary 
from the bite of a syphilitic child, or of the tertiary type in a 
woman who is suffering from the disease in its advanced stage. 
The matter would, of course, be brought at once to the attention 
of the physician, and the treatment is the same as it would be 
under any other conditions. 

Eczema of the nipple and areola, and occasionally extending 
over the entire breast, is a rare complication that may arise 
during the puerperium. Its treatment is both local and general, 
and can only be carried out by the physician. 

Insanity may occur at any time after conception and disap- 
pear within a few days or even hours, or it may continue 
throughout the entire pregnancy, into the puerperium, and even 
through the whole period of lactation. 

The insanity of pregnancy is usually melancholia, and is 
often so slight that it is entirely unnoticed, but it may, on the 
other hand, be very pronounced, with a marked suicidal ten- 
dency. 

The insanity of the puerperium, called ec puerperal insanity," 
is most often of the maniacal type, and is the most common 
of the three varieties. The mania usually appears within a 
month after delivery, either following the melancholia of preg- 
nancy or without any warning whatever. The patient is at first 
restless and disagreeable, and soon evinces a marked dislike for 
her husband and others who are most nearly related to her, 



PUERPERAL INSANITY. 



259 



or else the mania develops suddenly with no premonitory symp- 
toms. The woman becomes noisy, talkative, and incoherent, 
and her mind may dwell on religious subjects, or she may be 
profane, obscene, and vulgar, with an absolute loss of all sense 
of decency or modesty. The tendency to suicide or murder is 
always strongly marked, and the patient must be most carefully 
watched. 

The insanity of lactation is usually of the melancholic type, 
like that of pregnancy, and is most commonly seen in multiparas 
who have borne many children in rapid succession and whose 
general condition is greatly impaired. 

The causes of insanity cannot be stated very definitely, but 
may be supposed to include all conditions that greatly under- 
mine the general health of the patient. This would comprise 
severe injuries, mental disturbances, albuminuria, eclampsia, 
chorea, hemorrhages, septic infection, pronounced anaemia, and 
painful or prolonged labors. Heredity seems to play an im- 
portant part in the causation of this condition, and illegitimacy 
often exerts a sufficient effect on the mother to account for the 
insanity of pregnancy or of the puerperium among unmarried 
women. 

These cases are seldom fatal except through personal injury 
inflicted by the patient herself, but quite a number die eventually 
of exhaustion, and others become chronically and hopelessly in- 
sane. Unless the patient recovers entirely within a year it is 
almost certain that she will remain permanently demented, but 
the majority of cases do not last more than a few weeks or a 
month. 

There is a sudden transitory mania which sometimes occurs 
during labor, but it is probably an hysterical manifestation due 
to the severity of the pain, and it disappears within a few min- 
utes. 

The treatment of these cases lies entirely with the physician, 
and consists chiefly in building up the shattered constitution 
with nourishing and easily digested food, fresh air, good hygienic 
surroundings, and careful nursing and attendance. 

The maniacal cases should be placed in an asylum, unless 



2 6o A NURSE'S HANDBOOK OF OBSTETRICS. 

the circumstances warrant the employment of a sufficient num- 
ber of nurses for both day and night duty to keep the patient 
under constant surveillance, and even in the melancholic cases 
the suicidal and homicidal tendencies must be kept in mind at 
all times. 



XXI 

Abortion and Miscarriage 

Abortion, miscarriage, and premature labor are all terms 
which indicate the premature discharge of the foetus from the 
cavity of the uterus. When the embryo is expelled before the 
end of the third month of gestation, the word " abortion" is, 
technically, the correct term to employ ; while from the end of 
the third month up to the earliest date at which the child can, 
by any possibility, live (about six and a half months) the term 
" miscarriage" is used. If the woman is delivered at any time 
after the middle of the sixth month and within about two weeks 
of the proper end of her pregnancy, the birth is described as 
" premature labor." While, as has been said, the expulsion of 
the uterine contents during the first three months of gestation is 
technically termed " abortion," this work is so intimately asso- 
ciated in the public mind with some form of criminal procedure 
that the nurse should never use the word under any circum- 
stances, but group all such accidents occurring before the period 
of viability of the child under the general term " miscarriage." 

The first symptom of either abortion or miscarriage is usually 
pain of an intermittent character, followed soon by bleeding due 
to the separation of the placenta from its uterine attachment. 
In some cases the bleeding appears first, and the pain, which 
is of a " bearing down" type resembling that of labor, comes 
later. 

Premature emptying of the uterus at any time may be caused 
by fright, grief, or other form of severe nervous shock ; it may 
result from disease of the mother or of the foetus, or from 
external injury, such as a fall, or a blow or kick over the 
abdomen. In the latter class of cases the element of fright 
must also be considered. Whenever the mother is suffering 
from an acute febrile disease she will surely miscarry if the 
temperature reaches 105 ° F., and she may do so at a much lower 

261 



262 A NURSE'S HANDBOOK OF OBSTETRICS. 

degree. Hence in such cases the nurse must be always on the 
lookout and fully prepared for this accident. 

When abortion or miscarriage threatens the patient she is to 
be put in bed on her back and kept perfectly still until the 
physician arrives. If the symptoms are severe, one-sixth grain 
of morphine may be given hypodermically to relieve the pain 
and allay the nervousness of the patient. In many cases this 
treatment will be all that is necessary, and the pain will cease, 
the bleeding stop, and the case go on to full term without 
further interruption. In other cases the symptoms will increase, 
and eventually the foetus and its envelopes will be expelled from 
the uterus, either wholly or in part. The bleeding in these 
cases is seldom if ever enough to cause any serious alarm before 
the physician arrives, but it is of the utmost importance for the 
nurse to save for his inspection every particle of blood or other 
matter that comes away from the 'uterus. In many cases the 
embryo is so small that it is easily lost in a blood-clot, and 
unless the physician is afforded an opportunity of examining 
the discharges himself he cannot know exactly how much, if 
any, of the ovum has been expelled. Lacking this positive 
knowledge of the actual condition of affairs, the surgeon is 
obliged, in the interest of his patient, to proceed as if part, at 
least, of the ovum remained in the uterus, and a little care and 
forethought on the part of the nurse might have been the means 
of saving the patient the discomfort, not to say the danger, of 
a curettage under ether. 

Abortion and miscarriage are by no means the trivial matters 
that they are so commonly supposed to be by women in general. 
The process is distinctly an abnormal and unnatural one, and 
as the uterus is not prepared to cast off the placenta as it would 
at the normal end of pregnancy, some part of it is almost certain 
to be retained in the cavity of the womb. These retained frag- 
ments of placental tissue cause chronic inflammation of the 
membrane lining the uterus, even if they do not decompose and 
result in " blood poisoning," with the possible death of the 
patient. In cny event the outcome is bound to be serious unless 
the case is most carefully and intelligently treated, and even in 



CURETTAGE. 



263 



those cases in which the entire ovisac has apparently come away 
a thorough curettage under general anaesthesia is usually indi- 
cated as the safest procedure to follow. The nurse should use 
all her influence to impress upon patients the serious nature of 
abortion and miscarriage when proper treatment is neglected 
or refused, and it is safe to say. that the dangers to the woman 
are considerably 
train of a normal labor at term 



greater than are those which follow in the 




Fig. 126. — Lithotomy position. Limbs supported in Robb's leg«holder and covered with 
canton flannel leggings. 



If curettage is to be performed after abortion or miscar- 
riage, the preparations for the operation are the same as when it 
is indicated in any other condition. If there is sufficient time a 
soapsuds enema with one drachm of turpentine should be given 
to thoroughly empty the lower bowel. No solid food should be 



264 



A NURSE'S HANDBOOK OF OBSTETRICS. 



allowed within six hours of the operation, on account of the 
ether. 

The woman is to be etherized and prepared for operation in 
precisely the same manner as for forceps delivery except that, 
if possible, she should lie on a firm table instead of on the bed. 
She is to be placed in the lithotomy position (Fig. 126), and 
the kgs are to be supported in some form of leg-holder (Figs. 
127 and 128), or with the metal leg supporters screwed to the 





Fig. 127.— Author's leg-holder. 



Fig. 128.— Robb's leg-holder. 



sides of the table if the physician has them. A strong, narrow 
kitchen table is the best for use in private practice, and it is 
to be covered with a folded blanket, rubber sheeting, and a clean 
white sheet, all pinned securely under the corners. As the 
patient will be removed to her bed as soon as the operation 
is concluded, she may be anaesthetized in bed, and need not 
know that a table is to be used. Many women, who will submit 
to almost any surgical procedure so long as they are not re- 
moved from their beds, are stricken with terror at the mere sug- 
gestion of performing the same operation on a table, and it is 
best to keep all preparations out of their sight as far as possible. 
The instruments used for curettage are — 



INSTRUMENTS. 



265 




Fig. 129.— Sims's speculum. 




FIG. i 3 o.-Schroeder's vaginal retractor. 




FlG- I3I —Bullet-forceps. 




Fig. 



I32 .-Modified Goodell-Ellinger dilator. 



266 A NURSE'S HANDBOOK OF OBSTETRICS. 




3 "I 



Fig. 133. — Uterine sound. 




Fig. 134.— Placenta-forceps with heart-shaped jaws 




Recamier's dull curette. 



■»"'.-■■- I 



Thomas's large dull wire curette. 
Fig. 135.— Curettes. 




Fig. 136. — Sponge-holder. 



INSTRUMENTS. 



267 



Sims's speculum (Fig. 129), or a vaginal retractor (Fig. 
130). 

Bullet forceps (Fig. 131). 

Goodell uterine dilator (Fig. 132) occasionally. 

Uterine sound (Fig. 133). 

Placenta forceps (Fig. 134). 

Curette (Fig. 135) according to the case or to the individual 
preference of the operator. 

Sponge-holders (Fig. 136), at least four. 

Uterine applicators, four or five, wrapped with cotton. 

Double current catheter (Fig. 137). 




Fig. 137. — Two-way catheter. (Kelly.) 

A Kelly pad is to be placed under the patient's buttocks, to 
drain into a pail at the foot of the table, and there should be a 
small table at the head for the hypodermic syringe and other 
articles used by the anaesthetist. A chair should face the but- 
tocks for the operator, and at his right-hand side should be a 
low table within easy reach for his instruments. In private 
practice a dress-maker's " cutting-table," to be found in nearly 
every house, is best for this purpose. The carpet at the foot 
of the operating-table is to be protected with many layers of 
old newspapers, over which a sheet should be securely tacked. 

A suitable place must be provided for hanging a douche-bag, 
and if the operation is done at night this can usually be attached 
to the chandelier, which will be directly above the patient's but- 
tocks. 



268 A NURSE'S HANDBOOK OF OBSTETRICS. 

If daylight is to be used, the windows must be protected so 
that outsiders cannot see into the room, and yet the supply of 
light must be curtailed as little as possible. If there are lace 
curtains in the window they may be pinned securely together, 
or the windows may be covered with newspapers, white wrap- 
ping paper, or cheese-cloth. Another method is to cover the 
glass with whiting mixed with water to the consistency of a 
thick paste, as it would be used for cleaning silver. There is 
no danger that this covering will fall off, and it scarcely inter- 
feres at all with the passage of light. The operating-table is to 
be placed in such a position that the light will fall over the 
left shoulder of the surgeon. In the daytime the back of the 
operator's chair should be towards the window, and at night the 
patient's buttocks should lie directly under the middle of the 
chandelier. 

The nurse should have ready one dozen clean towels wrapped 
in parcels, sterilized or baked in the oven, plenty of boiled water, 
both hot and cold, and a long stout sheet, to be used as a leg- 
holder in case the physician does not bring one with him. 

The patient should be attired in night-gown and stockings 
only. The external genitals must be carefully cleansed, and if the 
pudendal hair is at all long or thick, it should be clipped closely 
with scissors, unless the physician wishes the parts shaved. 

After the patient has been etherized, placed in proper posi- 
tion on the table, and covered with sterile or bichloride towels, 
the operator will seat himself in the chair directly facing the 
vulva, insert the Sims speculum or the vaginal retractor to 
depress the perineum, and grasp the anterior lip of the cervix 
with the bullet-forceps to draw it forward. The nurse should 
have everything so arranged that it will not be necessary for 
her to leave the patient's side, and is now to assist the operator 
by standing or sitting at his left hand and holding the retractor 
and bullet-forceps in the manner shown in Fig. 138 while the 
operation is in progress. The patient's bed is to be made up 
with rubber sheet, white sheet, and draw-sheet, and the pillow 
should be removed and a large towel laid in its place for use as 
she comes out of ether. 



PREMATURE LABOR. 269 

Hot-water bottles (improvised most readily from beer- 
bottles with patent stoppers) should be at hand at the end of the 
operation, and if the case is at all a serious one the patient 
should be laid between blankets instead of sheets until she 
comes out of ether and reacts from the shock. 




Fig. 138. — Patient ready for curettage. Proper position of nurse, holding vaginal retractor 
in right hand, and bullet-forceps, drawing down anterior lip of cervix, in left. 

The after-treatment of abortion and miscarriage, whether or 
not curettage has been performed, consists in the practice of the 
most scrupulous cleanliness and in the frequent removal of all 
discharges from the folds and creases of the external genital 
organs. Douches should never be given except by the express 
order of the physician, and the patient is to remain in bed on a 
light but nourishing diet for at least ten days. 

Premature labor does not differ in its management to any 
marked degree from normal labor. There is, however, more 
of a tendency towards retained membranes or placenta, and the 



270 



A NURSE'S HANDBOOK OF OBSTETRICS. 



shock to the mother in her disappointment over the possible, if 

not actual, loss of her child often has a serious and very de- 
pressing effect on her nervous system and so upon her con- 
valescence. The care of the premature child is discussed in 
another chapter. 



XXII 

The Care of the Normal Infant 

As soon as the mother has been made clean and comfortable 
after the delivery the attention of the nurse may again be directed 
to the child for a brief period. 

The infant was wrapped in a warm flannel blanket and laid in 
a safe place at the time of its birth, and has been examined 
occasionally by the nurse to see that its breathing is satisfactory 
and that there is no bleeding from the cord. If the room is cold 
or the child is not warm and rosy, it should be surrounded with 
hot-water bottles, wrapped in towels to prevent the possibility 
of burning its delicate skin. The physician will, when the oppor- 
tunity offers, inspect the infant's body carefully for deformity, 
injury, or abnormality of any sort, and if it is perfectly de- 
veloped, inform the mother of its satisfactory condition. If 
deformity or injury is found, it is best to keep the knowledge 
from the mother for as long a period as possible by giving 
more or less non-committal replies to her interrogations, but 
as soon as she begins to suspect in the slightest degree that 
she is being deceived as to the child's condition it is wiser and 
kinder to make a clean breast of the whole affair and tell her 
the facts frankly, but in as gentle and sympathetic a manner as 
possible, and with every encouragement that can reasonably be 
offered. 

As soon as the room has been made presentable the nurse 
will find time to anoint the baby carefully with warm sweet oil 
or albolene, to remove the vernix caseosa which covers the body 
and is described on page 53. 

The oil is poured into a glass or cup, which is placed in a 
vessel of hot water and allowed to stand until it is thoroughly 
warm. 

The nurse sits in a low, comfortable chair without arms, in a 
part of the room protected from drafts, lays a soft bath towel or 

271 



272 A NURSE'S HANDBOOK OF OBSTETRICS. 

a small flannel blanket on her lap, and places the infant so that 
its feet are towards the source of heat, whether a fireplace, stove, 
register, or radiator, and its eyes away from the light. 

A clean flannel blanket is placed where it will warm thor- 
oughly and be ready to wrap the infant in as soon as it is 
anointed. 

The baby is now turned on its face, with its head extending 
slightly beyond the edge of the nurse's lap so that it can breathe 
freely, and the oil or albolene is applied gently but rapidly with 
a good-sized pledget of cotton to its back, and especially in the 
creases of the knees, buttocks, and neck, and back of the ears, 
where the vernix is most abundant. As soon as this is done a 
flannel binder is placed across its back, with the middle of the 
binder in the median line of the body, and the child is covered 
with a fold of the towel on which it is lying. The head is now 
thoroughly anointed with the oil and fresh cotton, to soften and 
remove the crusts of blood and particles of vernix caseosa that 
may be in the hair, but great care must be taken that nothing 
trickles down the forehead into the eyes. 

The child is next turned carefully on its back, with the flannel 
binder lying under it, and the front of the body anointed in the 
same way, particular attention being paid to the armpits and the 
creases in the elbows, groin, and under the chin. 

The physician may now dress the cord, or, if this has been 
left to the nurse, she will proceed to do it according to his direc- 
tions. In the absence of any definite instructions by the physi- 
cian a simple and very satisfactory method of dressing the cord 
is with absorbent cotton saturated with alcohol (ninety-five per 
cent). Enough alcohol is poured on the cotton to wet it thor- 
oughly, and it is then squeezed out until it is nearly dry. It is 
next shaped into a flat circular pad about three and one-half 
inches in diameter and a hole made in the centre with the 
finger. The cord is drawn gently through the hole and the 
cotton folded over it at the sides (Fig. 139). The stump of the 
cord will always have a tendency to lie in a certain position on 
the abdominal wall, and this should be respected and no attempt 
made to bring it into the median line if it falls naturally to one 



DRESSING THE CORD. 



273 



side. In other words, the cord is to be disturbed as little as 
possible, and merely covered with the cotton wherever it chances 
to lie. 




Fig. 139.— Method of dressing the umbilical cord. 

This dressing is held in place by the flannel binder, which, 
as will be remembered, is already lying under the infant and 
needs only to be brought over the abdomen on either side and 
pinned fairly snugly with small safety-pins a little to the right or 
left of the median line, as shown in the figure. 

Unless the dressing becomes soiled with urine or otherwise, 
it need not be disturbed at all but allowed to come off with the 
cord some time between the fifth and eighth day. If it is neces- 
sary to remove it, only such of the cotton as can easily be freed 
from the cord need be taken away and the fresh dressing applied 
exactly as in the first instance. The little tags and fibres of 
cotton that adhere to the cord will be sufficiently sterilized by 
the application of the fresh alcohol. 

A soft diaper may now be put on, and if the infant's feet 
are cold little knitted socks or bootees should be used. 

The baby may now be wrapped carefully in a clean, warm 
blanket and laid in a warm place, with its head covered and its 
eyes protected from the light, where it will usually grunt con- 
tentedly or go to sleep until the nurse has finished her other 
duties and made her preparations for its bath. 

The bath need not be given for several hours, or until every- 



274 



A NURSE'S HANDBOOK OF OBSTETRICS. 



thing has been put to rights, the placenta destroyed, the soiled 
linen removed to the laundry, and the entire household restored 
to a state of equanimity. 

The preparations for the infant's bath are important, and 
must be made with care. The articles needed are : an infant's 
bath-tub, which may be a small foot-tub resting on a chair or 
low table, or, preferably, a rubber tub supported on a wooden 
frame of sufficient height to prevent unnecessary stooping (Fig. 




Fig. 140. — Folding rubber bath-tub. (Davis.) 



140) ; a double wash-basin (Fig. 141), with one compartment 
for the face sponge and water and the other for the body sponge 
and water ; white castile soap of good quality ; two sponges of 
different sizes, the larger for the body and the smaller for the 
neck and ears ; a soft wash-cloth for the face and head ; baby 
powder of good quality in two boxes with puffs, one for the 
buttocks and groin and the other for the neck and armpits ; two 
pitchers of water, one hot and one cold ; a table with baby basket 



PREPARATIONS FOR THE BATH. 



275 



and scales; a rack for the infant's clothing placed near the 
source of heat to warm the garments ; a cup of warm boric acid 




Fig. 141.— Double wash-basin. 

solution on the table, with soft gauze wipes for the eyes and 
mouth; a low, comfortable chair, without arms, for the nurse; 
a rubber apron for the nurse and a good supply of soft towels ; 
two good-sized paper bags, pinned together (Fig. 142), for 



Hf 







Fig. 142.— Paper bags pinned together. One for soiled clothing to be washed; tbe other 
for articles to be destroyed. 



soiled articles ; and a bath thermometer. The infant's clothing, 
diapers, binders, and the like should be on the rack within easy 



276 A NURSE'S HANDBOOK OF OBSTETRICS. 

reach, and the baby basket is to be properly filled with everything 
that may be needed in the way of pins, cotton, gauze, pieces 
of old linen, etc. 

The excellent diagram of the ideal nursery (Fig. 143), taken 
from Rotch's " Pediatrics," shows clearly the proper arrange- 
ment of the various articles, and demonstrates perfectly the line 
of air-currents (or draft) when the room is heated by an open 
fireplace and ventilated, as it should be, by placing a well-fitted 
board about four inches wide under the lower sash of the 
window. A moment's study of this drawing will enable the 
nurse to understand clearly the course of air-currents, and, in 
any room, select a corner that will be free from draft. 

The bath is to be given daily at the same hour, in the late 
forenoon and just before a feeding time, so that the infant can be 
put to the breast as soon as its toilet is completed. 

The temperature of the bath may vary somewhat according 
to the age and strength of the infant, but it must never be cold 
enough to cause shivering or blueness of the extremities, and 
must invariably be gauged by the thermometer and not " guessed 
at" by the nurse. In a general way the following table, given by 
Rotch, will meet the requirements of most infants, but the effect 
on the child must be watched carefully and the temperature 
raised if necessary. 

TEMPERATURE OF THE BATH FOR DIFFERENT AGES. 

Age. Temperature. 

At birth 98 F. 

During first three or four weeks 95° F. 

One to six months 93 F. 

From six to twelve months 90 F. 

Twelve to twenty-four months 86° F. 

Then gradually reduce in summer to 8o° F. 

In third or fourth year, if possible, reduce to 75 F. 

The child is laid on its back on the nurse's lap, which is pro- 
tected with a rubber apron covered with a soft bath towel or 
woollen blanket, and undressed with the exception of its diaper 
and binder. The body is covered with folds of the bath towel 
on which the infant is lying, and the eyes and mouth are gently 



THE NURSERY. 



*77 




278 A NURSE'S HANDBOOK OF OBSTETRICS. 

bathed with the boric acid solution and small pieces of gauze or 
old soft linen. The baby's head and face are now washed gently 
and quickly with a soft cloth and soap and dried rapidly with a 
soft towel, care being taken that no soapy water gets in the 
eyes. As soon as this is done the head is protected from cold 
with a dry towel, and the binder and diaper are removed. The 
two paper bags, pinned together (Fig. 142), are on the floor by 
the nurse's side, and into one is thrown the diaper and other 
articles destined for the laundry, while the other receives the 
square of gauze from the centre of the diaper, of which more 
will be said later, the wipes used for the eyes and mouth, the 
cord dressing if it is removed, any pledgets of cotton that may 
have been used, and all other articles that are to be burned. At 
the end of the bath the bags are separated, folded up, and one 
sent to the laundry while the other goes to the furnace. If the 
bowels have moved, the fecal matter is to be wiped away care- 
fully with pledgets of cotton, which are deposited in the proper 
bag. 

The child's body is now to be soaped thoroughly and quickly 
with the sponge and water from the proper side of the double 
basin, and as soon as this is done the infant is lifted carefully into 
the tub and allowed to kick and splash for a few seconds. If the 
cord has not yet separated, the child's back is to be supported 
with one hand so that the navel will not sink below the surface 
of the water, but as soon as the umbilicus has healed the entire 
body may be immersed up to the neck. 

Nearly every baby will thoroughly enjoy its daily bath if it 
is begun immediately after birth and before the child is old 
enough to know the meaning of fear, but when the tub-bath is 
not commenced until the infant is several weeks old, or if it is 
ever dropped or otherwise frightened or injured in the bath, it 
may require great patience and perseverance to overcome the 
little one's terror of the water. 

The nurse must make sure that the water is of the proper 
temperature, and the baby is to be held firmly and dipped in 
the water slowly and carefully to avoid any sudden shock. When 
the child is, for any reason, actuallv afraid of the water, a thin 



THE INFANT'S BATH. 



279 



towel may be laid across the top of the tub, covering it entirely, 
and the baby held over the towel and then lowered very slowly 
and carefully into the water (Fig. 144) 



A few baths given in 




Fig. 144. — Lowering infant into bath. Tub covered with a towel to hide the water from a 

nervous child. 

this way may be successful in reassuring the infant and over- 
coming its fear. 

After a few seconds in the tub the child is returned to the 
nurse's lap, covered at once with a warm towel, and " spatted" 
softly until it is dry. A small soft towel is then used for drying 
the creases of the body and the armpits, groin, and buttocks, 
and talcum powder is applied lightly to all folds of the skin and 
places where moisture might collect. 

Remember that the baby is to be soaped and washed on the 
nurse's lap, and not in the tub until it is old enough to sit up; 
that separate sponges, wash-cloths, and waters are to be used 
for the body, buttocks, and face ; and that different powder- 
boxes and puffs are needed for the neck and buttocks. 

The infant, wrapped in the towel, is now laid in the scales 
and the weight carefully noted and recorded on the weight chart 



280 A NURSE'S HANDBOOK OF OBSTETRICS. 

after the bath. Before recording the weight the towel is to be 
weighed and its weight deducted from that of the infant and 
towel together. 

If the cord dressing has been removed it is replaced in the 
manner already described and the binder pinned carefully over 
it. The diaper, folded in triangular shape, is laid well up under 
the buttocks and on it is placed a square of folded gauze, lintine, 
or old soft pieces of napkins or table-cloths, which will absorb 
a good part of the urine and take up all the discharges from the 
bowels. These are to be changed and destroyed as soon as they 
become soiled, and their use will effect a great saving in washing. 
The diaper is now pinned carefully and fastened to the binder 
in front, and the infant's socks or bootees are put on and tied 
loosely. 

The outer clothing consists of three pieces, — an undershirt 
of stockinet with sleeves, a flannel petticoat without sleeves, and 
a muslin slip (Fig. 145). These garments are all made so that 
they can be fitted into each other before the infant is bathed and 
all slipped on at once. They should be drawn up over the feet 
and never put on over the head, for fear of frightening the baby, 
and after the sleeves are adjusted properly the child is turned on 
its face and the three layers of clothing buttoned in the back. 

It will be seen that this method of dressing the child causes 
no pressure on the chest or elsewhere, and allows perfect freedom 
of movement to all its muscles. As the infant is turned over but 
once in the entire process of dressing, it is not tired or excited 
as when the old-fashioned style of clothing is used. On this 
account it is not at all fretful, but more or less drowsy, after its 
bath, and quite inclined to nurse and go to sleep at once, to the 
great comfort of every one concerned. 

A folded diaper may be laid loosely under its buttocks, 
between its body and the undershirt, to protect its clothing, and 
its diapers must be changed the instant they are wet or soiled. 

In the case of a male infant the nurse should begin, when it 
is about a week old, to retract the prepuce, or " foreskin," cover- 
ing the glans penis, drawing it back a little every day until all 
the adhesions are broken up and the entire glans is exposed. 



INFANT'S CLOTHING. 



2ol 





282 A NURSE'S HANDBOOK OF OBSTETRICS. 

After this has been accomplished, usually in about ten or twelve 
days, the mother or other attendant should be instructed to re- 
peat the process two or three times a week for several months, 
or until the parts are entirely healed, to prevent the formation 
of new adhesions and to permit of the thorough cleansing of the 
glans and the removal of the curdy secretion called smegma 
which is formed in considerable amount. 

Adhesions between the prepuce and the glans penis are very 
common, and are a frequent cause of many of the nervous 
disorders of infancy and childhood. If the nurse has, at the 
outset, any difficulty in drawing back the prepuce she should 
consult the physician, but after the glans has once been fully 
exposed there will be no further trouble. 

Soap or soapy water should never be used for bathing the 
denuded and delicate tissue of the glans penis, but the parts 
should be cleansed and the smegma removed with warm salt 
solution or a weak solution of listerine. 

Similar adhesions are often found about the clitoris in female 
infants, but their destruction is not so easily accomplished, and 
should be left entirely to the physician. 

" Scalding" or chafing of the buttocks (intertrigo) is always 
the result of neglect to change the diapers and cleanse and 
powder the delicate skin as often as necessary, and no properly 
qualified nurse will ever permit such a condition to arise in a 
child under her care. Neglect of only a few hours is enough to 
start up irritation of this kind, and occasionally, when the nurse 
is out or resting and the child is in the care of some member of 
the family, the mischief will be done. 

Whenever redness of the buttocks appears the use of soap 
and water on the inflamed skin is to be discontinued at once, and 
the parts are to be cleansed only with warm sweet oil and dusted 
carefully with talcum powder, so that no vestige of moisture is 
present at any time. This will usually check the inflammation, 
and the skin will return to its normal healthy condition, but if 
the irritation continues and the chafing grows worse instead of 
better it should be brought to the notice of the physician, who 
will probably order some mild and soothing ointment. 



CARE OF THE SCALP. 



283 



Diapers that are but slightly clamp with urine may be dried 
thoroughly and used a second time, but before they are used 
again they should be washed, boiled, and ironed properly. It is 
better, of course, to use only diapers that are fresh from the 
laundry, and this should be done as far as possible and always 
if there is anv irritation of the skin. 




Fig. 146. — Infant's night-gown. (Rotch). 



Carelessness in cleansing the scalp will result in the condition 
known as seborrhoca capitis, which consists of an over-secretion 
of the sebaceous glands, mixed with dirt, forming a yellowish - 
brown, waxy-looking crust on the head. This will never occur 
if the child is properly cared for, and when the condition is 
encountered the crusts should be gradually softened with warm 



284 A NURSE'S HANDBOOK OF OBSTETRICS. 

sweet oil and removed as gently as possible, after which, if the 
head is kept clean, there will be no return of the trouble. 

The newly born infant requires a great deal of sleep, and is 
to be kept in its bed or bassinette except when it is removed for 
some special purpose, such as nursing or bathing. At a regular 
hour every evening, just before a nursing period (preferably a 
little before five o'clock), it is to be undressed completely and 
attired in its night-gown (Fig. 146) for the night. This gar- 
ment is made of stockinet or flannel, according to the season of 
the year, and, like the other clothing, opens in the back. It is 
worn until the daily bath next morning, which is best given just 
before the eleven o'clock feeding. 

The infant will, during the first few weeks of its life, sleep 
practically all of the time, but it must be expected to cry vigor- 
ously for at least half an hour each day in order to expand its 
lungs and develop the muscles of its chest and abdomen. It 
should be laid down at once after each nursing, so that it may 
go to sleep and digest its food properly, and if it cries, and 
examination shows that it is perfectly clean, dry, and comfort- 
able, it should be left alone to stop of its own accord, and never 
patted, rocked, or walked with. If possible the child should be 
kept in a room away from the mother until after the puerperium, 
in order that this process of disciplining may not disturb her rest 
and make her nervous. 

Systematic training of this kind during the first few weeks 
of the puerperium, coupled with a regular hour for undressing 
the baby and putting it to bed in a dark room for the night, will 
teach any child to go to sleep the moment it is laid in bed, and 
the habit will cling to it as long as the rule is rigidly enforced. 
If the plan is to be successful, it must be adhered to absolutely, 
and friends and relatives of the family must understand clearly 
that they cannot see the baby under any circumstances after five 
o'clock. 

There is not a healthy child living who has 10 be rocked or 
otherwise cajoled to sleep whose parents or nurses are not 
directly responsible for the whole matter, and while it may be 
very entertaining to ignore the welfare of the infant entirely and 



VISITORS AND OUTINGS. 285 

make a toy of it at first, the constant care and attention become 
most trying as the years go by, and especially so if other children 
are born and brought up in the same way. A child can be made 
a comfort just as easily as a trial and burden, and people whose 
children are up at all hours of the night, have to be rocked to 
sleep and stayed with for hours each evening, and protected 
from bogie men and other terrors of the nursery, have absolutely 
no one but themselves to blame. 

The fewer visitors allowed to see the baby the better, and 
these can only be admitted in the daytime. The child should 
never be " played with" by any one until it is at least six months 
old, and it is much better if it can be spared all excitement of this 
kind until it is in its second year. 

In these matters of discipline the nurse can only advise the 
parents as to the best course to pursue for their own personal 
comfort and the good of their child, but if they prefer to make 
themselves and everybody about them miserable for a number of 
years rather than forego an ill-timed frolic with the baby, they 
cannot be denied the pleasure of doing so. 

The temperature of the nursery should be kept at about 70 
P., and marked variations must be carefully avoided. The air 
must be kept pure and sweet at all times, and this is best accom- 
plished by placing a board four inches wide under the lower sash 
of one of the windows and lowering the top sash about half the 
distance, to allow for the escape of impure air, as shown in 

Fig. 143- 

The room should be at the upper part of the house, to avoid 
the dampness from the ground, and a sunny exposure should be 
had if possible. There should be no unnecessary hangings or 
furniture to collect dust and bacteria, and rugs are far better 
than carpets. 

The time when the baby can go out of doors depends upon 
the time of year, the weather, and the climate of the place of its 
birth. Babies born in the summer or in a warm climate may 
usually go out on dry, pleasant days when they are four or five 
weeks old, provided they are kept in the sun with their faces 
shielded from the light. Infants born in the winter or in a severe 



286 A NURSE'S HANDBOOK OF OBSTETRICS. 

climate are better off in the house, even up to the fourth or fifth 
month, but they should receive fresh air once or twice daily by 
being bundled up warmly and carried into a good-sized room 
with open windows, w T here they may remain for ten or fifteen 
minutes. 

The directions for nursing are given in detail in Chapter 
XXV., and it must not be forgotten that the baby requires a drink 
of tepid boiled water several times daily. This is best given 
very slowly with a medicine-dropper, and when the infant cries 
persistently between nursing periods a little water given in this 
way is often all that is necessary to quiet him at once. 

The umbilical cord usually separates from the body between 
the fifth and eighth day after birth, but its detachment may be 
delayed until the tenth, twelfth, or even fourteenth day without 
causing any harm unless signs of inflammation appear. The 
nurse will usually find the cord in the umbilical dressing when 
she removes the binder to give the baby its bath, and there may 
be a slight stain of blood on the cotton. If the bleeding con- 
tinues, as it may in very rare instances, the physician should be 
notified. In most cases the navel will be depressed somewhat 
and absolutely free from any evidence of inflammation. Md 
further treatment is required except to keep the part clean and 
dry, but a small protective pad of cotton under the binder will do 
no harm and may be used for a week or two longer if it is 
desired. 



XXIII 

The Premature and Feeble Infant 

There are three essential factors in the management of an 
infant that is puny and feeble, whether its low vitality is due 
to prematurity or to other causes operating on a full-term child. 
These are : to maintain its body temperature ; to provide 
nourishment which it can assimilate readily ; and to insure its 
absolute rest and quiet at all times. 

The best indication of an infant's ability to fight its own 
battles after birth is its weight. The mere fact that the child 
is born prematurely is of little consequence when compared 
with the number of pounds that it weighs, and a premature 
infant of five pounds will, in general, require no more care and 
attention than a full-term baby that weighs the same. 

The warmth of the infant's body may be kept up in two 
ways ; either by wrapping the child in a cotton jacket or by 
placing it in an incubator. 

As a safe general rule for guidance it may be said that 
babies weighing between four and a half and five and a half 
pounds are to be wrapped in cotton instead of being regularly 
dressed, while those weighing less than four and a half pounds 
should be placed in the incubator; and even larger children 
whose temperature is subnormal often do better in the cotton 
jacket. 

As soon as a small, feeble child is born it should be well 
anointed with warm olive oil or albolene, wrapped in zvann 
cotton and surrounded with hot-water bottles. The cord must 
be tied with special care, and is to be inspected for bleeding at 
frequent intervals, for there is a well-marked tendency to second- 
ary hemorrhage in this class of cases. 

As soon as the nurse has finished with the toilet of the 
mother she is to make a jacket of cotton and gauze in the 
following manner. A piece of gauze, shaped like the pattern 

287 



288 



A NURSE'S HANDBOOK OF OBSTETRICS. 



(Fig. 147), is procured, basted to a sheet of absorbent cotton 
about half an inch thick, trimmed roughly into shape, and cut 
out on the lines indicated. The infant is wiped dry with pledgets 
of warm cotton and the vernix caseosa removed carefully, espe- 



7 1*1. 






10 

?' 

I Opening \ 

\ ^° v 1 
\KTecK/ 


7 iti. 

Fold 




2 






Cut A 3 A in. 






Cut 4% in. 




^ 
•-»•. 
3 


k 

■ 


14- in. 


1 

*i 1 

1 





Fig. 147.— Pattern for improvised cotton jacket. Baste gauze of the above dimen- 
sions to one layer of cotton. Cut out on the solid lines as indicated and fold on the dotted 
lines. 

cially from the axillae, groin, and other places where it is most 
abundant. It must be remembered that there is more vernix 
caseosa on a premature infant than on a full-term child. The 
cord is dressed, a soft flannel binder applied, and the infant's 
body again carefully anointed with fresh warm oil or albolene. 
A small diaper is to be used, and this is best made of lintine, 
or pieces of an old soft napkin or table-cloth. The ordinary 
"bird's-eye" diaper cloth, if new, will be found too stiff, and 
the diapers themselves, if made for a full-term child, too large ; 
but old diapers may be torn into small pieces and answer as 
well as either of the other materials. 

The jacket is now to be warmed thoroughly, laid on the 
nurse's lap, or on a pillow, with the cotton side up, and the 
infant, clad only in binder and diaper, placed on it. The edges 
of the garment are next to be brought together in front, over 



DRESS FOR THE PREMATURE INFANT. 289 






Fig. 148.— Improvised turban of gauze and cotton for premature infant. 




Fig. 149.— Improvised cotton jacket, blanket, and turban. Small full-term infant dressed 
for purposes of illustration only. Compare Fig. 154. 

19 



290 



A NURSE'S HANDBOOK OF OBSTETRICS. 



the body and arms, and " caught" lightly but quickly with 
needle and thread (Fig. 149). The baby's feet may be encased 
in moccasins or bootees of flannel or knitted material, and the 
skirt of the jacket must be folded very lightly, so that it will not 
in the slightest degree interfere with the free movement of its 
legs. Its head must be protected from cold by means of an im- 
provised hood or turban (Fig. 148), made of a square piece of 
gauze folded over a triangular piece of cotton and applied as 
shown in Fig. 149. 

If the child weighs four and a half pounds or more, it need 
only be dressed in the cotton jacket described above and placed 
in a basket or box (a bureau drawer will answer in an emer- 
gency) and surrounded with hot- water bottles (Fig. 150). Care 




Fig. 150.— Infant premature at twenty-eighth week. Birth-weight, two pounds six and 
one-half ounces. Age, fourteen weeks. Treated in basket heated by hot-water bottles. 
Temperature of air in basket shown by thermometer introduced between the side of the 
basket and the blanket . ( Rotch. ) 



must be taken that the bottles are not too hot or laid too near 
the infant, for a burn can easily occur in cases of such low 
vitality. 

The basket or box containing the infant is to be placed in a 
quiet corner of the room, shielded from the light, and no 
visitors of any kind can be allowed to see the child, for any 
such disturbance and excitement is sure to be detrimental. 



THE INCUBATOR. 



291 



If the baby weighs less than four and a half pounds, an 
incubator should be purchased or rented and the child, dressed 
as above, placed in it at the earliest possible moment.* 

The principle of all incubators is the same, the only differ- 
ence being in the construction of the various kinds. It has long 
been known that the air surrounding a premature infant must 
be kept exceptionally warm, and formerly this was accom- 
plished by heating the room occupied by the child to a stifling 
temperature, to the great discomfort of the nurse or other 
attendant. 




Fig. 151.— Tarnier's incubator, exterior. (Tarnier and Budin, 1. c.) O, opening full 
length of box closed with a board that can be pushed to either side; M, so-called monk, 
a bottle of earthenware ; T, cover over opening at end of box, shorter than aperture which 
admits air ; V, glass cover ; b, b, buttons by which cover is easily lifted ; H, wheel revolved 
by escaping air. 



The incubator is nothing but a minature room in which the 
infant can lie, and is so arranged that its temperature can be 
raised to any desired degree, while its interior can always be 
inspected through a glass in the top (Figs. 151 and 152). Be- 
yond this ability to control the temperature perfectly the only 



* A modification of the Auvard incubator, known as the " Cooke 
incubator," has been devised by the author and is manufactured by 
Knauth Brothers, 220 Fourth Avenue, corner Eighteenth Street, New 
York, from whom it may be either rented or purchased. 



292 



A NURSE'S HANDBOOK OF OBSTETRICS. 



other essential feature of a satisfactory incubator is the appa- 
ratus which provides for its thorough ventilation. 

The incubator is usually heated by means of hot water, and 
this either circulates through a system of pipes, one portion of 




Fig. 152. — Tarnier's incubator, interior. E, wet sponge; P, partition between lower and 
upper compartments ; A, tube for escape of air; T, M, V, b, b, as in Fig. 151. 

which is exposed to a gas or alcohol flame, or the hot water 
is placed in tanks or bottles in the lower part of the incubator 
(Fig. 153) and renewed as often as it cools. In hospitals, 




Fig. 153. — Hot-water jus 



where there is a steam-heating apparatus, the incubator is often 
a stationary one, with its steam or hot water coil attached directly 
to the heating apparatus of the institution, but in private practice 
a movable incubator must necessarilv be used. 



CARE OF THE INCUBATOR. 



293 



The child lies on a shelf or platform, padded thickly with 
cotton, about six inches from the floor of the box and directly 
over the coil of pipe or the cans containing the hot water. 

Fresh air enters at the bottom, circulates around the heating 
apparatus, where it is raised to the proper temperature, passes 
over the shelf on which the infant rests, and escapes through a 
ventilator at the top. This ventilator is provided with an ane- 
mometer, or small revolving fan, to show whether or not there 
is a free circulation of air. As the warm air escapes from the 
ventilator at the top of the incubator it will cause the anemome- 
ter to revolve, and this revolution will be continuous unless the 
circulation of air is interfered with or the anemometer is out 
of order. Consequently it must be most carefully watched, and 
if the motion of the little fan ceases or becomes irregular a 
prompt investigation must be made. 

Another method of keeping track of the circulation of air 
within the incubator depends upon the appearance of the glass 
which covers the top. This should be clear and dry at all 
times, and if it becomes moist and cloudy on the inside it is 
proof positive that the ventilation is not good. 

A wet sponge is to be kept in the incubator to moisten the 
air, but there must be a sufficiently rapid circulation to prevent 
any of the moisture from collecting on the glass. 

A thermometer, of sufficient size to be read easily, is to be 
placed by the side of the infant in such a position that it can 
be seen clearly through the glass, and the temperature of the 
interior must be kept between 88° and 92 ° F. and with as 
little variation as possible. It is best to start at 92 °, and then 
reduce the temperature very gradually and evenly to 88°, reach- 
ing this point by the end of about a week and holding to it for 
several weeks longer, as the physician may direct. 

Sudden changes in temperature must be avoided absolutely, 
and thermometer and anemometer be watched constantly. 

As the cry of a premature infant is very feeble at best, it is 
often quite inaudible when the child is shut up in an incubator, 
and the closest attention must be paid to the condition of the 
baby at all times. 



294 A NURSE'S HANDBOOK OF OBSTETRICS. 

Many persons are of the impression that once the child is 
placed in a good incubator no further special precautions need 
be taken, but this is a most mistaken idea. Premature or under- 
developed infants require the most solicitous care in every way, 
and to merely keep them at a proper temperature will avail 
nothing unless the other details of their management are care- 
fully carried out. 

Rest is a most important factor in the rearing of such chil- 
dren and they must be shielded from excitement and every dis- 
turbing influence. Visitors invariably flock to see an unusually 
small child, and an " incubator baby" will be sure to attract a 
crowd of curiosity seekers as soon as its existence becomes 
known. The nurse must positively refuse to let any one see 
the child except the members of its immediate family, and these 
favored few can only be allowed occasional and very short 
glimpses. 

All manipulation of the baby must be avoided except for 
absolutely necessary purposes, such as changing its clothing, 
administering nourishment, altering its position, or cleansing 
its body. 

Light is to be curtailed by placing a shawl or other piece 
of dark cloth over the glass top of the incubator, and loud or 
sudden noises must be forbidden. 

The skin, in these cases, is extremely delicate and tender, 
and diapers must be changed the instant they become wet or 
soiled, or severe " scalding" will occur within a few hours. 

The child is not to be bathed except as is necessary for 
cleanliness, and wnen the diapers are changed the buttocks must 
not be washed with soap and water, but wiped carefully with 
cotton dipped in warm oil or albolene and then dried with cotton 
alcne. 

The cotton jacket is to be changed twice daily, care being 
taken that the fresh one is warm and ready for instant use the 
moment the old one is removed. 

As soon as the nurse can spare the time from her other duties 
a more workmanlike jacket of cotton and gauze is to be made for 
the infant, and the hastily improvised turban is to be replaced 




Fig. 154. — Premature infant (about seventh month) properly attired in cotton jacket 
and hood, and removed from incubator only long enough to be photographed ; weight, two 
pounds three and one-half ounces ; present age, five days. Case of central placenta praevia, 
seen in consultation with Dr. E. C. Pixley, of New York City. 



FOOD FOR THE PREMATURE INFANT. 



295 



by a properly constructed hood (Fig. 154). As a great many 
jackets and hoods will be required by the child before it is strong 
enough to give them up entirely, a good supply should be pro- 
vided in order that fresh clean ones may be had at a moment's 
notice. 

The weight and temperature of the child are both matters of 
the greatest importance, for, as in the case of any baby, if 
the child loses weight and its temperature goes up, it is an 
evidence that its food is either insufficient or of improper 
quality. The temperature is to be taken in the rectum and 
recorded on a chart every night and morning, and the weight is 
to be taken and carefully recorded once a day, at the time when 
the cotton jacket is changed. It is unnecessary to say that any 
rise in temperature or loss of weight must be reported at once 
to the attending physician. 




Fig. 155. — English breast-pump. 

The best food for a premature baby is mother's milk, not only 
because it is especially adapted by nature to the needs of the 
child, but because it is very desirable to keep up the secretion 
of the mammary glands, so that, when the baby grows older 
and stronger, it can nurse directly from the breast. 

The milk may be expressed from the breast with the hands 
or with a breast-pump, and is to be received into a perfectly 
clean cup and fed at once, before it has had time to cool. 

The only breast-pump worth considering is that known as 
the "English breast-pump" (Fig. 155). This must be kept 
scrupulously clean and free from any curds or particles of sour 



296 A NURSE'S HANDBOOK OF OBSTETRICS. 

milk, and should be boiled at least once daily, and preferably 
each time it is used. The nurse must be very gentle in applying 
the breast-pump to the nipple, or the delicate tissues may be 
injured and much trouble result. After the nipple has been 
thoroughly cleansed, as for a nursing baby, the air is to be 
forced out of the bulb of the breast-pump and the bell placed 
gently but firmly against the breast so that the nipple comes 
exactly in the centre of the opening. The bulb is now allowed 
to expand slowly and gradually, and in a moment or two the 
milk will be seen to spurt out in two or three very fine jets. 
As soon as the bulb is fully expanded and full of air the pump 
is to be lifted from the breast, the bulb again compressed, and 
the bell again pressed firmly over the nipple as before. If for 
any reason it becomes necessary to remove the pump from the 
breast while it is still exerting suction on the gland, a little com- 
pression of the bulb will restore the pressure within the pump 
and it will come off of itself. Under no circumstances should 
it ever be pulled forcibly from the breast, and the use of the 
breast-pump should never at any time be painful to the mother. 
In some cases it will be found necessary to combine massage of 
the breast with the use of the pump, and if the milk does not 
flow freely when the pump is used the gland should be stroked 
gently and firmly with the finger-tips from the edges towards 
the nipple. Both breasts should be emptied at each feeding-time 
and the milk poured into a cup which stands in a basin of hot 
water, until enough is collected for one meal. 

It seldom happens that a premature baby is strong enough 
to nurse from a bottle, and the milk must be fed with a spoon, 
a medicine dropper, or some other appliance that will do away 
with all effort on the part of the child. 

Dr. Breck has devised a " feeder" for premature infants 
(Fig. 156) consisting of a graduated glass tube with a small rub- 
ber nipple at the smaller end and a rubber finger-cot at the 
larger. The cot serves as an air reservoir, and, when the nipple 
is placed in the infant's mouth, slight intermittent pressure on 
the cot will enable the child to get the milk without any effort 
whatever beyond that of swallowing. 



METHODS OF FEEDING. 



297 



To fill the " feeder" the nipple and cot are removed, a cork 
fitted snugly in the smaller end, and the proper quantity of 
milk poured in through the larger opening. The cot is then 
attached to the top, the " feeder" inverted, and, after the cork 
is removed, the nipple is slipped over the smaller end. 



-~ « 



Fig. 156. — Feeder for premature infant. (Rotch.) 

The amount of milk for each feeding should at first be from 
two to three drachms, and the food should be given as often as 
every hour during the day and every two hours at night. 

The care of the breast-pump and nursing-bottle, or " feeder," 
whichever is used, is of the utmost importance, for, if germs 



298 A NURSE'S HANDBOOK OF OBSTETRICS. 

of any sort are allowed to collect in them, the milk will be 
contaminated and the life of the infant will be greatly en- 
dangered. The cot and nipple are to be cleansed with soap and 
water inside and out, rinsed thoroughly, and boiled for five 
minutes before each feeding. The bottle, or glass portion of the 
" feeder" or breast-pump, must also be cleansed with the greatest 
care by scrubbing, rinsing, and boiling. 

It is well to have a number of " feeders," bottles, nipples, and 
cots, so that several of each may be boiled at one time and 
kept in sterile boric acid solution until they are needed. 

When mother's milk cannot be secured, cow's milk, modified 
in the manner described in Chapter XXV., must be given; but 
the physician must always regulate the strength and quantity 
of the food, for the problem of feeding a premature child with 
artificial nourishment presents many difficulties, and is too 
serious a matter for the nurse to undertake on her own respon- 
sibility. 

In general it may be said that the premature baby is to 
receive food of half the strength and in half the amount, but 
twice as often as would be given to a full-term child. 

The feeding in every case must be regulated to meet the 
needs of the particular baby under treatment, but if the manage- 
ment is at all successful at the outset it will not be long before 
milk of the usual strength for a normal infant of correspond- 
ing age can be given with safety. 

The nurse will often be asked if a premature infant will ever 
develop as well and be as strong and sturdy as one born at 
term. It may safely be said that if the child can be made to 
live and thrive during the first few weeks there is no reason why 
it should not ultimately be as robust and healthy as any other 
baby (Fig. 157). 




Fig. 157.— Infant premature at thirty weeks. Birth-weight, four and one-quarter 
pounds. Treated in incubator sixty-four days. Age, nine months. Weight, seven- 
teen and one-half pounds. (Rotch.) 



XXIV 

The Accidents, Injuries, and Diseases of the New-Born 

The accidents that may occur at or shortly after birth 
include asphyxia and hemorrhage from the cord. 

Asphyxia has already been discussed on page 210. 

Hemorrhage from the cord may be primary, due to the 
slipping or loosening of the ligature, or secondary from the base 
of the cord when it separates from the body. In the first instance 
the bleeding is from the end of the cord and not from its base, 
and can be controlled by the proper application of a fresh liga- 
ture. The secondary hemorrhage, from the base of the cord, 
occurs at about the fifth to the eighth day when separation takes 
place. It is often preceded by a slight jaundice, and is not an 
actual flow of blood but a persistent oozing, which frequently 
resists every form of treatment until the infant dies in a con- 
dition of exsanguination. This variety of hemorrhage is of 
rare occurrence, and may be due to that peculiar condition 
known as the " hemorrhagic diathesis," in which the individual's 
blood shows no disposition to coagulate, and bleeding from any 
denuded surface is persistent and often profuse ; or the child 
may be the subject of a syphilitic taint. 

The treatment by the nurse of secondary hemorrhage from 
the cord consists in the application to the bleeding surface of a 
piece of cotton saturated with liquor ferri subsulphatis (solution 
of the subsulphate of iron, to be had of any druggist). The 
physician should be notified promptly, and if by the time he 
arrives the use of the styptic has not effectually controlled the 
oozing, he will doubtless pass two long needles at right angles 
to each other through the base of the umbilicus and apply a 
tight " figure-of-eight" ligature (see Fig. 97). The needles must 
be removed at the end of six or eight hours and an antiseptic 
dressing applied. If this form of bleeding is at all severe and 
persistent, recoveries seldom take place, and even if the umbilical 

299 



3°o 



A NURSE'S HANDBOOK OF OBSTETRICS. 



hemorrhage is controlled, bleeding may appear in the nose, 
mouth, stomach, intestines, or abdominal cavity ; or the infant's 
body may develop purpuric spots at various points. 

The injuries to the new-born infant are those which occur 
during labor, either from pressure or from manual or instru- 
mental assistance to delivery. 

Fracture of a long bone or dislocation of an extremity may 
be the result of a version, or may occur in a breech case with 
the arms extended above the head when they are brought down 
into the vagina. Fracture of the clavicle (" collar bone") or of 
the jaw. or dislocation of either of these bones, may follow for- 
cible efforts to extract the after-coming head in cases of breech 
presentation. These cases, of course, can only occur when the 
physician is present, and their treatment rests with him entirely. 

Fractures in the newly born infant usually heal rapidly, but 
it is often somewhat difficult to keep the parts in good position 
while repair is going on. 

Dislocations should be reduced at once, or there will be great 
danger of permanent deformity in the joint. 

Injuries to the head caused by the forceps usually disappear 
within a few days, even when they are quite marked at first. If 
there is actual laceration of tissue, which will only occur when 
the instrument slips, or if there is a destruction of tissue-vitality 
from very prolonged pressure, it is quite probable that perma- 
nent scars will remain. Neither of these injuries will happen 
when the instruments are judiciously used, and any scar that 
may result will be so small and faintly marked by the time the 
child is five or six years old that it will be scarcely noticeable. 

Pressure from forceps may seriously affect the brain-tissue, 
causing paralysis of certain groups of muscles (Fig. 158), or 
an acute traumatic meningitis may develop ; and the same con- 
ditions may occur when no instruments are used. 

Prolonged pressure on the head during a protracted first 
stage, where the membranes rupture before the os is fully 
dilated, causes a swelling of the scalp at the point where it is 
encircled by the cervix. This is called " caput succedaneum >> 
(Fig. 159), and in its milder forms is very common. It is due 



CAPUT SUCCEDANEUM. 



301 



to an extravasation of serum into the tissues of the scalp at 
the portion surrounded by the os and free from pressure, and 




"■^ 



Fig. 158. — Facial paralysis of new-born child. (Ahlfeld.) 

it is the more marked the longer the first stage is delayed. The 
portion of scalp rendered cedematous in this manner varies, of 






Fig. 159.— Caput succedaneum. Male, two hours old. (Rotch.) 

course, with the position and presentation, and the condition 
always disappears in a day or two without treatment of any sort. 



302 



A NURSE'S HANDBOOK OF OBSTETRICS. 



Another swelling of the scalp which resembles caput succe- 
daneum in certain respects is caused by an effusion of blood 
between the parietal bone of one side and the overlying scalp. 
This is seldom present when the child is born, and may not be 
noticed for two or three days, when the existence of a swelling 
will be observed, and it will be seen to increase gradually in 
size until about the seventh day after labor, when it remains 
stationary for a time and then slowly disappears. This condi- 
tion is termed "cephalhematoma" (Fig. 160), and usually 



■^^EF 




W 


- 







Fig. 160.— Double cephalhematoma. Infant four days old. (Rotch.) 



ends iii recovery without treatment. It may be due to press- 
ure in normal labor, or by forceps, but it is also occasionally 
seen in breech cases in which no instruments were used nor pro- 
longed pressure exerted on the after-coming head. These cases 
are not common, and require no further mention. 

The diseases of the new-born infant are ophthalmia, icterus, 
spina bifida, mastitis, vaginal hemorrhage in female infants, 
umbilical hernia, umbilical vegetations, congenital cyanosis, and 
tetanus. 



OPHTHALMIA NEONATORUM. 



303 



Ophthalmia neonatorum is a disease of the eyes charac- 
terized by a profuse purulent discharge due to infection from 
the genital canal at the time of birth and usually of gonorrhceal 
origin. The disease appears two or three days after birth, pro- 
vided the infection occurred at this time, but as the septic matter 
may be introduced into the eye at a later period by dirty cloths 
and neglect of the proper care of the child, the onset of the 
trouble may be much later. Both eyes are usually affected, and 
they are first suffused with a watery discharge and somewhat 
congested. Within twenty-four hours the lids are very much 
swollen, and a thick, creamy, greenish pus is found under them. 
Later the swelling becomes so marked that the eyes cannot be 
opened at all, opacities of the cornea occur, the conjunctiva is 
ulcerated and then perforated, and the eye collapses and atro- 
phies. 

The treatment consists, first, in the use of a five per cent, 
solution of protargol dropped into the eyes immediately after 
the labor, and this should always be done as a preventive meas- 
ure whenever there is any suspicion of gonorrhceal or other 
infection of the vagina. If the disease develops in spite of this 
prophylactic treatment, the infant is to be kept in a dark room 
and the eyes bathed at intervals of from twenty to thirty 
minutes with sterile ice-cold saturated solution of boric acid. 
Iced cloths must be kept constantly on the eyes until the inflam- 
mation has subsided, and when the boric acid solution is used 
the lids must be separated so that it will flow freely into the eye 
and reach every part of the diseased tissues. Whenever the 
iced cloths are changed or the boric acid is used fresh pieces of 
gauze must be employed and the old ones destroyed at once by 
burning. If opacities appear on the cornea in the form of small 
milky-white spots, the physician must be notified immediately, 
for, unless the most energetic measures are adopted without 
delay, the sight will be destroyed. 

The nurse must remember that this is a distinctly infectious 
disease, and that there is extreme danger of conveying it to 
others and of setting up an acute infection in the maternal 
genital tract. Even the eyes of the nurse herself may become 



304 



A NURSE'S HANDBOOK OF OBSTETRICS. 



infected unless she is most painstaking in her methods. The 
fingers should be covered with fresh sterile gauze when sepa- 
rating the lids, and thumb-forceps (Fig. 161) should be used 
for changing the iced cloths. 




liiliinilli! 



Thumb-forceps. 



Ophthalmia neonatorum is a serious condition which may 
result in total blindness, but if suitable treatment is adopted at 
the very outset of the disease and intelligently carried out the 
sight can usually be saved. The entire treatment is, of course, 
under the direct supervision of the physician, and in severe 
cases he will often deem it best to call an oculist in consultation. 

Icterus neonatorum (jaundice of the new-born) is a fairly 
common condition of somewhat uncertain origin, but believed by 
many to be due to infection at the umbilicus. It often appears 
in its milder forms among strong, healthy infants, the yellow 
color of the skin showing first on the second or third day and 
increasing in intensity until the ninth or tenth, when it begins 



SPINA BIFIDA. 



305 



to disappear. No treatment is required unless the infant shows 
symptoms of severe constitutional disturbance, and in the vast 
majority of cases a favorable outcome may be expected. 

Spina bifida (Fig. 162) is due to the congenital absence of 
one or more vertebral arches, usually at the lower part of the 




Fig. 162.— Spina bifida of dorsal lumbar region. Infant forty-eight hours old. Died when 
ten days old. (Rotch.) 



spine. This allows the membranes covering the spinal cord to 
bulge outw r ard, forming a soft fluctuating tumor filled with 
cerebrospinal fluid. The tumor is diminished by pressure and 
enlarges when the infant cries. The disease is usually fatal, 
although a certain few cases have been cured (Fig. 163). The 
most common outcome is ulceration of the sac followed by its 
rupture and the escape of its contents. Convulsions then occur, 
and death follows within a few hours. 

When the tumor is very small and shows no signs of in- 
creasing in size, it may merely be protected from injury and 
infection by carefully applied dressings, but the more severe 
cases are treated surgically if at all. 

Mastitis (inflammation of the breast) is occasionally seen in 
very young infants of either sex. The affected breast becomes 
swollen, tense, hot, red, and painful, and the disease usually 
appears during the first two or three weeks of life. The breast 

20 



3 o6 A NURSE'S HANDBOOK OF OBSTETRICS. 

is to be anointed gently with camphorated oil and protected 
from injury by a soft, loose, cotton dressing. In other respects 
it is to be left severely alone, and under no circumstances should 




Fig. 163. — Spina bifida. Spontaneous cure. Male, four and one-half years olo (Rotch.) 

it be squeezed, rubbed, or massaged. Nearly all cases will 
recover without any trouble, but if, as may possibly happen, 
an abscess should form, it is to be treated surgically. 



UMBILICAL HERNIA. 



307 



A vaginal discharge of blood is not an uncommon occur- 
rence among female infants, the flow appearing a few days after 
birth, and usually causing the parents considerable anxiety. It 
is of no consequence whatever, and will disappear of itself in a 
few days without any treatment. 

Umbilical hernia (rupture at the umbilicus) may appear 
during the first few weeks of life, but usually not until a later 
period. The tumor may be made to disappear entirely on press- 
ure, and reappears when the pressure is removed and the child 
cries. 

The treatment consists in reducing the hernia and applying 
a well-padded hernia button (Fig. 164) about the size of a 




Hernia button. 



half-dollar, which acts as a truss and is held in place by two 
strips of adhesive plaster crossed in the centre (Fig. 165). In 




Fig. 165.— Method of attaching hernia button. Usually two strips are enough, and they 
may be cut much shorter than is indicated in the illustration. 

the absence of a regularly made hernia button, a half-dollar or 
a large bone or wooden button, padded well with flannel, may 
be used. 

If the hernia can be controlled perfectly for six months a 
cure will result. When the button is removed to be cleaned 
continuous pressure must be maintained with the finger until 
the pad is replaced and properly secured. Great care must be 
taken to prevent irritation of the skin by the plaster, and the 
" Z-O" plaster, manufactured by Johnson & Johnson, will be 
found the least likely to cause trouble. 



308 A NURSE'S HANDBOOK OF OBSTETRICS. 

Umbilical vegetations are sometimes seen after the cord 
has separated, in the form of little red friable tubercles varying 
in size from that of a pin-head to that of a large pea. The 
vegetations bleed readily, and are merely redundant granula- 
tions and of no special consequence. The physician can usually 
cure them promptly by removal with scissors or cauterization 
with nitrate of silver (" lunar caustic''). 

Coxgexital cyaxosis occurs in those cases known popularly 
as " blue babies," and manifests itself at any time from a few 
hours to a few weeks after birth. The infant's body and, 
especially, its face and extremities acquire a dusky bluish or 
purplish hue, which ma}' be almost imperceptible when the 
child is resting, but which is very marked after exertion of 
any kind. 

The condition is due to a congenital defect in the circulatory 
apparatus, usually in the heart itself, which interferes with the 
flow of blood through the lungs, and so deprives the infant of 
its proper amount of oxygen. 

Most of the cases die in early infancy, although some may 
live to be ten or twelve years old. 

The only treatment is that directed towards the comfort of 
the little sufferer, and consists of inhalations of oxygen to relieve 
urgent symptoms, and rest, quiet, good hygienic surroundings, 
and nourishing food of a simple character. Brandy or other 
stimulant may be given when the dyspnoea is severe, but no 
treatment can have any curative effect, and the disease will 
always prove fatal eventually. 

Tetanus is a very rare disease in this country. It is due 
to the action of a special germ, the bacillus tetani, which in the 
newly born infant enters the system through the umbilicus. 

The disease begins between the third and tenth day after 
delivery, and the first symptom noticed is a stiffness of the 
muscles of the face and an inability to nurse or swallow. This 
is followed by a contraction of the muscles that control the jaw, 
causing trismus or " lockjaw," and within ten or twelve hours 
the spasm extends to the muscles of the neck and back, causing 
opisthotonos, or a rigid arching backward of the body so that 



TETANUS NEONATORUM. 



309 



it can rest on the neck and heels with the trunk and limbs above 
the level of the bed (Fig. 166). 




Fig. 166. — Opisthotonos. The characteristic convulsion of tetanus. 

As a rule, death occurs within twenty-four hours, but if the 
child can be made to live for a few days it may possibly recover. 

If an epidemic of tetanus is prevalent in any locality, it is 
best for a prospective mother to go to some other place which 
is free from the disease, for her confinement. 

The treatment rests wholly with the physician, and, as the 
patient is unable to swallow, all drugs must be given hypoder- 
mically. The child must be disturbed as little as possible, for 
any sound or movement aggravates the condition. 

Tetanus antitoxin, if it can be secured, combined with stimu- 
lants and opiates, and chloroform by inhalation when the spasms 
occur, are the only means we have for combating the disease. 



XXV 

Infant Feeding 

The best food for a baby is that designed for it by nature, — 
breast milk. The best breast milk is that furnished by the 
infant's own mother, and the next best is that from another 
woman acting as a wet-nurse. 

If the child's mother is unable to supply milk of a proper 
quality and in sufficient amount for its needs, and if the services 
of a suitable wet-nurse cannot be secured, the next best food is 
cow's milk, properly modified to meet the requirements of the 
child. 

Whenever the mother is able to do so she should nurse her 
infant as far as she can, and then make up the deficiency with 
modified cow's milk ; for even a limited quantity of breast milk is 
better for the child than none at all, and the effect of nursing not 
only stimulates the breasts to the production of better milk from 
day to day, but greatly aids the process of involution by which 
the uterus and other pelvic organs return to their normal condi- 
tion after labor. 

Breast milk is to be preferred to any modified milk, no 
matter how carefully prepared, for the reason that it is exactly 
what the child requires, while the other is at best only an 
imitation ; it is absolutely free from germs, while cow's milk 
always contains a certain number of bacteria ; it is delivered to 
the child in proper quantity and at a proper temperature, while 
bottle food may escape through the nipple either too rapidly or 
too slowly, and is often too hot at the beginning of a feeding 
and too cold at the end. Moreover, the bottles and nipples are 
apt to become sour even when the utmost attention is given to 
their care ; the quality of the milk is always liable to vary ; and 
errors not infrequently occur in the preparation of the food. 

Hence we have to consider four distinct methods of feeding, 
named below in the order of their respective values : 
310 



MOTHER'S MILK. 



311 



1. Mother's milk. 

2. Wet-nurse. 

3. Mixed feeding. (Partly breast milk and partly modified 
cow's milk.) 

4. Artificial feeding. (Modified cow's milk exclusively.) 
Mother's Milk. — Before we can expect a mother to furnish 

good milk for her infant we must see to it that her breasts are 
in the best of condition for performing their functions (Fig. 
167). This necessitates the adoption of measures early in preg- 




Fig. 167. — Soft, flabby breasts. Not well adapted to nursing. 



nancy that will prepare the mammary glands for the work that 
lies before them. These measures have already been discussed 
in the chapter on the Management of Pregnancy, but will be 
reviewed here briefly. 

The breasts should be bathed night and morning with soap 
and tepid water, to keep the skin in good condition, and rinsed 
after each morning bathing with cool or even cold water, accord- 
ing to its effect on the patient, to stimulate the activity of the 
glands. During the last two months of pregnancy the nipples 
are to be anointed with white vaseline or albolene every night, 
and this is to be washed off carefully in the morning to remove 



312 A NURSE'S HANDBOOK OF OBSTETRICS. 

any crusts of dried colostrum that may have formed. This dry- 
ing of colostrum on the nipples is one of the most potent factors 
in the causation of soreness or tenderness of these organs, and 
the daily application of the vaseline or albolene effectually pre- 
vents the colostrum from " crusting" and so irritating the deli- 
cate tissues of the parts. If the nipples are short or flattened, 
they should be drawn out with the thumb and forefinger every 
night and morning and held in this position for at least five 
minutes. This simple procedure, practised regularly twice daily 
during the last eight or ten weeks of gestation, will often work 
wonders with nipples so small or flat that nursing is, at first, 
apparently out of the question. 

The condition of the woman's general health has much to do 
with her ability to furnish good milk, and it goes without saying 
that corsets or other garments that compress the chest will inter- 
fere seriously with the development of the breasts. 

Assuming that everything is favorable for nursing, the child 
is not to be put to the breast until the mother has had a good 
rest from the effect of her labor, and, if possible,' not until after 
she has had a nap of a few hours. Usually the baby can begin its 
nursing about four or five hours after birth, after which it is 
to be put to the breast regularly, every four hours, day and night 
for the first two days. During this time the breast secretes 
nothing but colostrum, a laxative substance containing prac- 
tically no nourishment whatever. If the infant does not seem 
satisfied with this diet of colostrum, the nurse may give it a 
five per cent, solution of milk-sugar made up with boiled water. 
One teaspoonful of sugar to twenty of water makes the solution 
in the required proportion, and it is best given in an ordinary 
two-ounce vial fitted with a small rubber nipple (Fig. 168). If 
a small enough nipple cannot be obtained, one may be impro- 
vised by taking the rubber cap of a medicine dropper and 
piercing it with a good-sized needle. 

At or about the end of forty-eight hours the true milk begins 
to appear in the breast, and the infant should now be nursed 
every two hours from six a.m. to ten p.m., with one night feed- 
ing at two a.m. This plan gives the mother two uninterrupted 



HOURS FOR NURSING. 



313 



periods of four hours each for sleep, and it is to be adhered 
to until the child is six weeks old, after which the intervals 




Fig. 168. — Two-ounce vial with nipple. For administering nourishment, water, or sugar 
solution to a very young infant. 

between the feedings can be increased gradually until the fourth 
month is reached, when the night feeding can often be omitted 
entirely. 

For convenience of reference the hours for nursing may be 
tabulated as below : 

First two days Every four hours. 

Third day to sixth week ( 2, 6, 8, 10, 12 a.m. 

I 2, 4, 6, 8, 10 p.m. 

Six weeks to ten weeks { 2 -3°> 7> 9-3<>, 12 a.m. 

I 2.30, 5, 7.30, IO P.M. 

Ten weeks to four months f 2.30, 7, 10 a.m. 

1 1, 4, 7, IO P.M. 

Four months to nine months { ?' IO AM - 

1 1, 4, 7, 10 P.M 

Of course, different meal-times might be chosen with the 
same intervals between, but the hours given are those which are 
least likely to interfere with the meals and other affairs of the 



314 A NURSE'S HANDBOOK OF OBSTETRICS. 

household. Nurses, and physicians as well, will find it a great 
convenience to adopt the same feeding hours for all infants 
coming under their professional care, for this plan will do away 
entirely with the possibility of any confusion or misunderstand- 
ing as they go from one family to another. The child can easily 
be " started" at six o'clock every morning for the first six weeks, 
and this will bring the other meal-times right for the entire day. 
Afterwards the mother may be allowed to sleep until seven 
o'clock before the regular daily programme is begun. 

The care of the nipples and of the infant's mouth, both 
before and after nursing, is of the utmost importance, for dirty 
nipples are the most common cause of infection of the breast, 
and also infect the baby by setting up disease of its mouth and 
digestive tract ; while a dirty mouth is almost certain to cause 
disease of the nipples. Immediately before and after each 
nursing the entire breast is to be bathed gently with tepid water 
and a little castile soap, and the nipple washed off with alcohol 
(ninety-five per cent.). Also, the infant's mouth is to be wiped 
out very gently with warm boiled water, applied with a soft 
piece of gauze wrapped over the end of the forefinger. A solu- 
tion of boric acid or of borax may be used for this purpose, but 
in the writer's opinion the boiled water answers perfectly well. 
The utmost gentleness must be exercised in cleansing the infant's 
mouth, for the tissues are extremely delicate, and if any force is 
used abrasions may be caused which may afterwards serve as 
starting-points for infection. 

The effect of the warm water on the breast is to favor the 
flow of the milk in the first instance, and after the nursing is 
over it adds greatly to the comfort of the patient by removing 
any of the secretion that may have trickled down over the skin. 
The alcohol (itself an antiseptic) sterilizes and probably tough- 
ens the nipple, and as it evaporates almost instantly it cannot 
exert any harmful effect on the infant, as might be the case with 
ordinary antiseptic solutions made up with more or less poison- 
ous drugs. The cleansing of the infant's mouth is for the pur- 
pose of removing any curds or other substances that might, by 
decomposition, infect the nipple or cause trouble to the child. 



CARE OF THE BREASTS. 315 

When the true milk begins to appear in the breast (about the 
second or third day), the patient is apt to suffer somewhat from 
a feeling of fulness and tenderness in the distended organs. 
This can be relieved by the application of a well-fitted and fairly 
snug breast-binder (see Fig. 124), so adjusted that it will raise 
the breasts up on the front of the chest and prevent them from 
hanging down at the sides and " dragging." After the binder 
has been placed in position under the patient's back and is ready 
for pinning, the breast on one side is to be raised up as high as 
possible over the chest wall, a pad of absorbent cotton about the 
size of the hand placed at its outer side, and held in this position 
by the patient herself while the other breast is treated in the 
same way. This will bring the two breasts close together in 
the median line, with a deep furrow between them, and it is well 
to place a small strip of absorbent cotton in this depression be- 
tween the organs to absorb perspiration and any possible excess 
in the secretion of milk. The milk at this time and for the next 
few days is apt to flow very freely and in much greater amount 
than is needed by the child, and other little pads of absorbent 
cotton should be placed over the nipples to take up the overflow 
and keep the clothing sweet and clean. These pads must be 
changed at very frequent intervals, for if any sour milk is 
allowed to collect it will not only tend to make the nipples sore, 
but it may seriously affect the child as well. The binder is, of 
course, to be unpinned for each nursing and replaced again as 
soon as the child is through and the breasts have been thor- 
oughly cleansed. It can usually be discarded entirely after a few 
days, and it must be remembered that its only purpose is to 
support the breasts, and that if too snugly pinned it will compress 
the organs and interfere with their functions. 

If the child is to nurse properly it must be properly held by 
the mother, and while most women seem to know instinctively 
how to support an infant at the breast, many are so awkward 
about it that definite instructions must be given them. First of 
all, the baby must be comfortable, and so placed that it can 
reach the nipple without any effort. Its head and shoulders 
should rest on the arm corresponding to the breast to be nursed, 



3 i6 A NURSE'S HANDBOOK OF OBSTETRICS. 

and the mother's other arm should reach over the child's bodv 
so that the hand can support its back. This is much more easily 
managed when the woman is sitting up, but during the early 
days of the puerperium the patient is, of course, on her back in 
bed. At this time a small pillow placed under her elbow is of 
great assistance to her in supporting the weight of the child, and 
when she is able to be up she should use a chair with arms, on 
which she can rest her elbow or upon which a pillow or cushion 
can be placed when the infant is at its meal. 

The child should be made to understand that it is to begin 
nursing as soon as it is put to the breast, and it should con- 
tinue to nurse vigorously, with occasional brief rests for 
breathing, until its meal is finished, when it is to be removed at 
once and laid in its bed. A baby that " dawdles" at the breast, 
or one that is fretful and peevish, either is not hungry or there 
is some fault with the milk, the nipples, or with its own ability to 
nurse. In any event, such a child should be taken from its 
mother's arms as soon as a fair trial shows that it is not going 
to nurse properly, for it is the worst possible policy to keep 
a crying child at the breast for a long period when it is obviously 
unwilling or unable to take its nourishment. It should be kept 
away for a full interval, or until another feeding time comes 
round, when it will probably have learned what is expected of it 
and proceed to its duty properly and without delay. 

If, however, it continues to refuse the breast after this has 
been done, the physician should be consulted. He may find that 
the quality or quantity of the milk is at fault, that there is 
trouble with the nipples, or that the infant itself is ailing in 
some way. 

If everything is satisfactory the baby should nurse heartily 
at its regular meal-times, which, of course, grow farther and 
farther apart as the child's age increases. It should be hungry 
as each feeding time comes round, satisfy itself in at least twenty 
minutes, and at the end of the meal fall into a comfortable, 
drowsy condition or even drop off to sleep. 

The infant should be weighed every day and its weight 
accurately recorded in pounds and ounces. It will be found that 



VOMITING AND REGURGITATION. 317 

during the first few days of its life it will lose weight in every 
case, because its food, being chiefly colostrum, contains very 
little nourishment and it is obliged to live on its own fat. This 
initial loss in weight is always to be expected, and usually 
amounts to about ten ounces, after which the child begins to 
gain, and should be back to its original birth- weight by the 
time it is ten days old. Thus there is a normal initial loss of 
ten ounces in weight, normally regained in ten days' time. From 
this time on the child should gain steadily from day to day, 
until at the age of six months it should weigh twice as much as 
it did at birth. 

Besides gaining regularly in weight and strength, a baby 
should be happy and good-natured when awake, but inclined to 
sleep a good part of the time between nursings. It should be 
hungry at its proper nursing times, but not before, and its diges- 
tion should be perfect, as evidenced by the absence of vomiting 
and the passage of smooth, bright yellow stools entirely free 
from curds or mucus. 

Vomiting must not be confused with " regurgitation," which 
is a purely normal process by which the stomach gets rid of an 
overload of food. Vomiting is always accompanied by the symp- 
toms of nausea. It may occur at any time, but usually long 
after nursing. The child cries, grows pale, and even blue, about 
the mouth, develops a cold sweat on the forehead, and, with 
more or less effort, expels a quantity of sour, bad-smelling, 
curdled milk from the stomach. This process may be repeated 
at frequent intervals, and the child is evidently sick. Regurgi- 
tation occurs immediately after nursing and at no other time. 
The baby is bright and happy, and merely opens his mouth 
and lets the excess of milk run out on his dress. It is, in 
other words, nothing more than an overflow, and, far from 
doing the baby any harm, does him good by relieving his 
distended stomach. The milk is not sour, and the baby is 
obviously perfectly well. 

Occasionally a child appears to be hungry between feeding- 
times, when in reality it is only thirsty, and it should be given 
small sips of tepid boiled water until it has satisfied its thirst. 



318 A NURSE'S HANDBOOK OF OBSTETRICS. 

There is no danger of giving it too much water, and it should be 
allowed to drink until it stops of its own accord. 

In no case should the baby be put to the breast more fre- 
quently than at the regular feeding-hours already named, for a 
young infant requires nearly two hours in which to digest its 
food, and if it is nursed too often one meal will be taken into 
the stomach before the preceding one is digested, with the result 
that vomiting and indigestion will occur. As the child grows 
older it takes more milk at a nursing, and a longer period is 
required for the digestion of its food, so that the intervals 
between the nursings are necessarily lengthened. The point is 
to give its feedings far enough apart to allow the stomach a 
short period of rest before each nursing. 

Usually the milk from one breast will be enough for a very 
young infant, in which case alternate breasts should be used 
for each nursing, but as the child grows older it will be neces- 
sary to put it to both breasts at every feeding. There is no 
harm in doing this at any time, provided the milk of one breast 
alone does not seem to be in sufficient quantity to satisfy the 
child. 

The baby should never be played with or " stirred up" soon 
after a nursing, for such excitement will almost surely inter- 
fere with digestion and cause vomiting and other disorders 
of a serious nature. In fact, a child should never be played 
with at all until it is past six months old, but allowed to 
devote all its energies to eating, sleeping, and developing in 
every way. 

When, after every precaution has been taken to secure proper 
milk for the child, the food still does not " agree," the trouble, 
if not with the child itself or with the condition of the nipples, 
can usually be traced to alterations in the quantity or the 
quality of the breast milk. 

If the quantity is at fault, and the baby is not receiving 
enough nourishment, the following signs will serve to indicate 
the nature of the trouble : 

I. The baby will wake before its regular nursing time and 
be obviously hungry. It will cry and fret, refuse water with 



INSUFFICIENCY OF MILK. 319 

apparent disgust, and, when nursing is permitted, seize the 
nipple ravenously and nurse with great vigor. 

2. It will continue to nurse long after the breast is empty, 
in its effort to secure enough food, and will cling to its mother 
and cry in a fretful way when an attempt is made to remove it 
from her arms. As has been said, a normal child, receiving 
normal milk, should be perfectly satisfied within twenty minutes 
at the most, after which it should drop the nipple of its own 
accord. 

3. The breast itself, when examined just before a nursing 
hour, will not be full of milk as it should be, and on prolonged 
palpation it may be impossible to express any milk at all from 
the nipple. When the meal-time arrives the breasts should, 
under normal conditions, be firm and tense but never painful, 
and very slight pressure should be enough to cause the milk to 
escape in fine jets. 

4. The child's weight will go down and its temperature will 
go up. In the chapter on the Care of the Normal Infant stress 
was laid on the importance of keeping a careful daily record of 
its morning and evening temperature taken in the rectum, for 
the onset of fever, coupled with a loss of weight, is one of the 
most significant indications that the amount of nourishment is 
not sufficient. 

With these four points in mind, the nurse should have no 
difficulty in knowing when the amount of milk secreted is too 
small. 

To increase the milk flow the condition of the mother's 
health should be looked into carefully, and she is to be shielded 
as much as possible from worry, grief, overwork, or other 
causes of low vitality. If coffee is included in her diet, it 
should be stopped entirely, for this beverage has a decided ten- 
dency to diminish milk secretion. She should drink milk, or 
cocoa, in its place, and extra milk should be taken between meals 
and at night before retiring. It must be remembered, however, 
that too much milk is apt to upset the stomach, especially in 
certain individuals, and lime water or vichy should be added to 
each glassful as a preventive against this form of gastric dis- 



320 A NURSE'S HANDBOOK OF OBSTETRICS. 

turbance. If symptoms of indigestion develop, the milk should 
be stopped at once, and dispensed with until the stomach is again 
in good working order. 

Certain articles of food increase the milk flow to a marked 
degree, and among these may be mentioned beets and all kinds 
of shell-fish, notably crabs. The writer has had under his care, 
recently, a nursing woman who, after eating one or two soft- 
shelled crabs at night, would be obliged to put on a breast-binder 
before morning in order to relieve the tension in her breasts. 
Crabs and similar rich articles of food should never be given 
to the woman while she is still in bed, and none of the various 
drugs, supposed to increase the secretion of the breasts, should 
be administered except by order of the physician. 

An excessive flow of milk is of rare occurrence after lactation 
is fully established, but when it does occur to such an extent 
that it soils the patient's clothing and keeps her in a constantly 
uncomfortable condition, it may often be checked by the adminis- 
tration of one or two cups daily of strong black coffee. 

" Caked" breasts, popularly supposed to be due to over-dis- 
tention with milk, seldom occur after the woman is up and 
about, and their treatment is discussed in the chapter on the 
Management of the Puerperium. 

If the quality of the milk is at fault the case will probably 
have to be referred to the physician. 

Up to this time no mention has been made of the chemical 
constituents of milk, but unless a nurse has a fair knowledge 
of these matters she cannot understand the subject of infant 
feeding in an intelligent way. 

Milk is a natural emulsion, and consists, roughly speaking, of 
thirteen per cent, of solids and eighty-seven per cent, of water. 

The solid substances are fat, sugar, proteids, and salts t and 
of these it is only necessary to consider the first three, for the 
salts are unimportant in many ways and never vary to any great 
extent. 

The fat of milk is in the cream, the sugar is the kind known 
as "lactose" or (C milk-sugar," and the proteids make up the 
curd. 



CHEMISTRY OF MILK. 321 

In good specimens of mother's milk there is, approximately, 
four per cent, of fat, seven per cent, of sugar, and two per cent, 
of proteid. It will be seen that this makes up the entire thirteen 
per cent, of solid matter, but, as a matter of fact, the true 
proportions are slightly less than the round numbers given, 
leaving room for a small percentage of salts. 

Normal mother's milk, as it leaves the breast, is a sterile fluid, 
absolutely free from germs, blood-corpuscles, or pus-cells. It 
should have an alkaline, possibly neutral, but never an acid, 
reaction, and its specific gravity should be from 1027 to 1032. 
Colostrum cells should be absent after the twelfth day, and 
the fat cells should be small, numerous, and of uniform size. 

The proteids of milk vary directly with the specific gravity, 
— that is, the higher the specific gravity the higher the proteids, 
and vice versa. If we know the amount of cream in a given 
specimen of milk, it is possible to make a fair estimate of the 
proteids in a very simple way. Professor Holt, of the College 
of Physicians and Surgeons, has devised a little apparatus, con- 
sisting of an hydrometer and jar, for ascertaining the specific 
gravity of milk, a pipette, and two long graduated cylinders with 
glass stoppers, for estimating the percentage of fat. 

The milk to be examined is to be taken from the middle of a 
nursing, or, if it is removed from the breast artificially, after 
about half the entire amount has been extracted. 

This milk is put into one of the glass cylinders with the 
pipette and should fill it exactly to the graduation marked O. 
If specimens from both breasts are to be examined at the same 
time, both cylinders are used. The cylinders, properly filled 
and securely corked, are set away in a temperature of 70 ° F. 
and left undisturbed for twenty-four hours, after which time the 
cream line will be distinctly visible and the percentage may be 
read on the scale. But this is cream and not fat, which is to 
the cream as 3 is to 5. Thus, if a specimen of milk shows seven 
per cent, of cream, we have : Fat : 7 : : 3 : 5, or four and one- 
fifth per cent, of fat. 

The estimation of the proteids is not quite so simple, but 
it is by no means difficult. 

21 



322 A NURSE'S HANDBOOK OF OBSTETRICS. 

We can determine accurately the amount of fat in a given 
specimen, and fat, being the lightest part of the milk, tends to 
lower the specific gravity ; so that the more fat in a specimen 
the lower the specific gravity would naturally be. Proteid, on 
the other hand, is the heaviest part of the milk, and the greater 
the percentage of proteid, the higher will be the specific gravity. 
Hence : 

(a) If both fat and specific gravity are high the proteids 
must also be high, or the amount of fat will bring down the 
specific gravity. 

(b) If the fat is low and specific gravity high, the proteids 
are probably about normal, the high specific gravity being due 
to the small amount of fat in the specimen. 

(c) If the fat is high and the specific gravity low, the pro- 
teids are again probably about normal, the low specific gravity 
being due to the large amount of fat. 

(d) If both fat and specific gravity are low, the proteids must 
also be low, for otherwise the small amount of fat would make 
the specific gravity high. 

In collecting the milk for examination great care must be 
taken to handle it as little as possible, and the glass cylinders 
for making the cream tests must be scrupulously clean, or the 
milk may sour before the cream has had time to rise. If at 
the end of twenty-four hours the cream line is not sharply 
defined, the specimen may be allowed to stand six hours longer 
before the percentage is recorded. 

Any marked variations in the proportions of fat and proteids, 
and the presence of any foreign substances in the milk, such as 
blood or pus, will cause, in the infant, indigestion of a more 
or less serious degree. The most common form of disturbance 
is that due to an increased percentage of proteids, and is evi- 
denced by constipation and the presence of curds in the stools. 
If the condition is not corrected promptly, serious illness may 
result. When fat is present to an excessive degree the infant 
vomits and has diarrhoea. It is not difficult to keep these two 
sets of symptoms in mind when it is remembered that the pro- 
teids, being the curd of the milk, would, if in excess, naturally 



VARIATIONS IN QUALITY. 323 

cause curds in the stools ; and that the fat, being an oil, would, 
if in too great amount, tend to the production of diarrhoea. 

Both fat and proteids are increased by a diet that is largely 
of animal food and diminished by one consisting chiefly of 
vegetables. In cases where the proteids are in too great amount 
it might be possible to remedy the matter by putting the woman 
on a vegetable diet and then, if necessary, making up the de- 
ficiency in fat by giving her cream to drink. 

Fright, worry, pain, or any other nervous shock, increases 
the proteids in the milk, and the patient must be shielded from 
these disturbances as far as possible. 

Menstruation increases the proteids, but the increase depends 
largely upon the amount of pain that the woman suffers at this 
time. Not long ago it was thought best to stop nursing entirely 
if the menstrual function returned during lactation, but it has 
been found wiser to be governed by the amount of suffering that 
the woman undergoes, and not take the child from the breast 
unless the mother's pain is extreme and the infant plainly shows 
the effect of the change in the milk. Ordinarily it is better to 
let the baby undertake the extra digestive strain for a few days 
each month than to subject him to the greater risk of an entire 
change in diet. 

The presence of blood or pus in the milk is an absolute 
indication for stopping all nursing at the affected breast. This 
condition is usually due to injury or inflammation of the breast, 
and if the milk remains after an apparent cure has been effected, 
the child must not be allowed to nurse until, by microscopic 
examination, it is known that all evidences of suppuration have 
entirely disappeared. 

Pregnancy, when occurring during lactation, causes a 
marked decrease in the percentage of fat. It is another, and 
the only other, positive indication to stop nursing entirely. The 
milk is not good for the child, and the mother cannot properly 
nourish herself, her baby, and the foetus in utero, while the reflex 
connection between the breasts and the uterus would make 
nursing under such conditions a very probable cause of abortion. 

As has been said, the presence of blood or pus in the milk 



324 A NURSE'S HANDBOOK OF OBSTETRICS. 

and the occurrence of pregnancy are positive contraindications 
to nursing; any of the other conditions may or may not be, 
according as they can or cannot be corrected by diet or other 
treatment; and lastly, there are some women whose milk is 
apparently perfect in every respect and yet who cannot nurse 
their children because, from some unknown reason, the milk 
does not and cannot be made to " agree." 

Wet-Nurse. — Theoretically the wet-nurse is the best substi- 
tute for mother's milk, but practically it is usually better to try 
" mixed feeding" or adopt artificial feeding entirely. The wet- 
nurse is not easily secured ; she is expensive, and usually she is 
an extremely " cranky" and disagreeable person to have in the 
house, causing trouble with the other servants and making herself 
generally unpleasant in her assurance that the family will put up 
with anything rather than have the baby's food changed again. 

The majority of wet-nurses are unmarried women secured 
from some public maternity hospital, as women with homes and 
husbands are not apt to neglect their own children in this way, 
and the probable, if not actual, lack of morality in the nurse is 
an added reason for making her an undesirable member of the 
family. Aside from this, however, an unmarried woman usually 
makes the best wet-nurse, not only because she parts with her 
own baby with little or no regret, but she has no husband to 
appear at frequent intervals and demand her wages or upset the 
entire household by threatening to take her away. 

In selecting a wet-nurse a woman should be chosen whose 
baby is as nearly as possible of the age of the baby for whom 
her services are required. She should be a woman of neat and 
cleanly habits, and, preferably, one of more or less phlegmatic 
disposition, and both she and her child should invariably be seen 
and examined by the physician for evidences of disease of any 
and every sort. 

As has been said, a single woman usually makes a better 
nurse than one who is married, and the fact that the married 
woman has lost her infant through death does not help matters 
any, for her grief will usually be enough to spoil her milk by 
increasing the proteids. 



MIXED FEEDING. 325 

If the unmarried woman is physically all that could be de- 
sired, she should be given the preference, for the essential thing 
is to secure a good food for the baby without any regard to 
other considerations. The question is often asked if there is 
not danger that the baby will acquire the disposition and char- 
acter of the wet-nurse, and the best answer is that the proba- 
bilities are exactly the same as that a bottle baby will take on 
the manners and morals of a cow. 

Milk is milk, and if it agrees with the baby its source is a 
matter of no consequence whatever. 

After the nurse has been selected and the baby given into her 
charge the general directions governing the feeding are the same 
as when the infant nurses at its mother's breast. 

Mixed Feeding. — This is the method to be adopted when 
the mother has some milk, of good quality, but not in sufficient 
quantity to fully satisfy the child. 

The hours for feeding, according to the age of the child, are 
the same whether the baby is at the breast or on the bottle, and 
if the mother has not milk enough to satisfy her infant at every 
feeding she can often skip one or two nursing hours and give 
modified milk in place of the omitted breast feedings. 

This plan should always be tried when the quantity of breast 
milk is below normal and its quality is good, for, as has been 
said, it is better for both mother and child to have the breast 
milk utilized as far as possible. 

The modified milk to be used in mixed feeding is prepared in 
the proportions suited to the age of the child and given in the 
same quantity that would be allowed if the baby were exclusively 
on the bottle. 

Artificial Feeding. — This is a most important subject and 
one that can only be considered here as it may be applied to a 
normal and perfectly healthy infant. 

The various patented baby foods will not be discussed in any 
way. Directions for their use go with every bottle, and while 
each one claims to be better than all the others, and proves its 
claims by the publication of pictures of fat and usually rhachitic 
babies, they are all more or less bad and of no real value except 



326 A NURSE'S HANDBOOK OF OBSTETRICS. 

in certain cases where they may be used by the physician's direc- 
tion to tide over a period of travel or to increase the carbo- 
hydrates in a food greatly diluted to remove its proteids. 

Condensed milk, like the patented foods, contains too much 
sugar and too little fat to give it any value except on occasions, 
and while it also makes fat babies, these children, like those fed 
exclusively on the advertised baby foods, have no real honest 
strength and are liable to break down in childhood at the first 
attack of any serious disease. 

Mothers often point with pride to healthy grown children, 
and state that they were brought up on this, that, or the other 
food, but the fact remains that if they had been attacked by any 
serious disease of infancy they would have died, when babies 
fed on modified cow's milk might have weathered the gale with- 
out difficulty. The explanation is that these children were for- 
tunate enough to escape any severe disease until they had been 
on a general diet long enough to enable them to resist it. That 
the " baby-food babies" are fat is merely because sugar makes 
fat, and these foods are chiefly composed of sugar, which is 
necessary as a preservative, just as the housewife adds sugar to 
her " preserves" to keep them from spoiling. 

Goat's milk and ass's milk are not worthy of consideration, 
although it is true that their constituents approach more nearly 
the proportions of breast milk than do those of cow's milk. The 
objection to their use lies in the fact that they are not easily 
obtained, and that even if they can be had they are not exactly 
the same as mother's milk and must be modified with as much 
care and attention as is paid to the preparation of cow's milk. 

The only milk worthy of serious consideration as a substi- 
tute for breast feeding is that obtained from a herd of healthy 
cows. The milk from one cow, so long regarded as best for 
bottle feeding, is no longer used. It was formerly supposed 
that " one cow's milk" was less liable to change than that from 
mixed milkings, but it is now known that while the milk from 
a herd preserves a very constant average of quality, that from 
one cow is always subject to marked change. 

The milk sold in bottles in the cities is usually of fairly good 



ARTIFICIAL FEEDING. 327 

quality, owing to existing laws regulating the management of 
dairies and the shipment and sale of milk. The best bottled 
milk to be had in New T York is that known as " certified" or 
"guaranteed," milk and sold by certain dealers only. This dif- 
fers from ordinary bottled milk only in that it is milked, shipped, 
and sold strictly in accordance with suggestions made by a 
committee appointed by the New York County Medical Society 
to investigate the milk supply of the city. Ordinary bottled milk 
may be up to all the requirements of a good food, or it may 
not, but certified milk can always be relied upon in every way. 
If the child is at all feeble, or, in any event, if the parents can 
afford the slightly additional expense, certified milk should be 
used instead of the ordinary kind. 

It has been said that mother's milk contains, approximately, 
four per cent, of fat, seven per cent, of sugar, and two per cent, 
of proteids. 

Mixed cow's milk — that is, milk which has been stirred up, 
so that any cream which may have risen is thoroughly mixed 
with the rest of the milk — contains, approximately, four per 
cent, of fat, four per cent, of sugar, and four per cent, of 
proteids. 

At first sight it would seem that the only necessary step in 
modifying cow's milk to meet the requirements of an infant 
would be to dilute it one-half with water, giving fat, two per 
cent. ; sugar, two per cent. ; and proteids, two per cent. ; and 
then adding two per cent, of fat and five per cent, of sugar to 
make the formula read, fat, four per cent. ; sugar, seven per 
cent. ; proteids, two per cent. This formula, from a chemical 
stand-point, is exactly the same as that of mother's milk, and it 
would be a proper food for the baby were it not for the fact that 
the proteids of cow's milk differ materially in point of digesti- 
bility from those of breast milk and must be greatly diluted 
before a young infant can assimilate them. By the time the 
child is about three months old its system has become accus- 
tomed to the proteids of cow's milk, the proportions of which 
have been gradually increased from day to day until, by this time, 
the formula is the same as that of mother's milk. 



328 A NURSE'S HANDBOOK OF OBSTETRICS. 

To prepare milk for an infant under three months of age 
we find that it is most convenient to use, as a basis, cow's milk 
containing twelve per cent, of fat, four per cent, of sugar, and 
four per cent, of proteids. This is called " twelve per cent, 
milk," or " 12-4-4 milk." 

To prepare food for a baby between the ages of three and 
nine months it is most convenient to use cow's milk containing 
eight per cent, of fat, four per cent, of sugar, and four per cent, 
of proteids. This is called "eight per cent, milk," or "8-4-4 
milk." 

Ordinary mixed cow's milk, containing, as has been said, 
four per cent, each of fat, sugar, and proteids, is called " four 
per cent, milk," or " 4-4-4 milk." 

To make " eight per cent." or " twelve per cent." milk it is 
only necessary to add to ordinary mixed (4-4-4) milk the re- 
quired amount of fat in the form of cream. 

Cream is nothing more than milk containing an excess of fat, 
and is of two kinds, — " gravity" cream and " centrifugal" cream. 

" Gravity" cream is that which rises to the top of a milk- 
bottle, or which, in the country, may be skimmed from the milk- 
pans. It contains fat, sixteen per cent. ; sugar, four per cent. ; 
proteids, four per cent. 

" Centrifugal" cream is that made with a centrifugal machine, 
and is sold in the cities in small sealed bottles as " cream." It 
is about as thick as honey, and contains fat, twenty per cent. ; 
sugar, four per cent. ; proteids, four per cent. 

The problem now is to make either " eight per cent." or 
" twelve per cent." milk by the addition of the proper quantity 
of either " gravity" or " centrifugal" cream to ordinary mixed 
(4-4-4) milk. 

These various formulas may seem a trifle confusing until 
they are placed in order, thus : 



Fat 






Sugar. 


Proteids. 


4 per 


cent. 


4 per cent. 


4 per cent 


8 




4 


" 


4 " 


12 




4 


" 


4 " 


16 




4 


( i 


4 " 


20 ' 




4 


<< 


4 " 



ARTIFICIAL FEEDING. 329 

It will now be seen that nothing varies but the fat, and that 
the fat varies only in the perfectly regular progression of 4, 8, 
12, 16, 20. 

The first formula is that of ordinary mixed milk, and the 
next two are those of the desired products for use as the basis 
of the baby's food ; while the last two are those of the perfectly 
familiar kinds of cream in every-day use. 

In addition to the method of making " eight per cent." or 
" twelve per cent." milk by mixing cream and ordinary milk in 
proper proportions, the same results can be obtained by removing 
a definite amount of milk from the top of an ordinary quart 
milk-bottle in which cream has had time to rise. The method 
of removing this " top milk" and the amount to be removed 
will be taken up later. 

Thus we have three methods at our disposal, — the use of 
" gravity" cream, of " centrifugal" cream, or of " top milk." 

If " twelve per cent." milk is desired, it is made as follows: 

From gravity cream, by adding one part of 4-4-4 milk to two 
parts of gravity cream, thus : 



Fat. 


Sugar. 


Proteids 


16 


4 


4 


16 


4 


4 


4 


4 


4 


36 


12 


12 



From centrifugal cream, by mixing equal parts of 4-4-4 milk 
and centrifugal cream, thus : 



Fat. 


Sugar. 


Proteids 


20 


4 


4 


4 


4 


4 



2)24 



From top milk, by taking nine ounces from the top of the 
bottle as it comes from the dairy. The best way to remove the 
top milk is with the little dipper, holding exactly one fluid ounce, 



330 



A NURSE'S HANDBOOK OF OBSTETRICS. 



devised by Dr. Henry Dwight Chapin and known as the 
" Chapin dipper" (Fig. 169). The first dipperful is to be taken 



Fig. 169. — Chapin dipper. 

off with a teaspoon, or the milk will slop over when the dipper 
is lowered into the bottle. It is, of course, distinctly understood 
that the milk is to be dipped out and not poured, for any tipping 
of the bottle will disturb the cream and alter the proportion of 
fat in the top milk. 

This " twelve per cent." milk is now to be modified for the 
infant's use, and it is found most convenient to prepare twenty 
ounces of food each time in order to make the proportions come 
right. 

It has been said, in speaking of breast milk, that it should 
be alkaline or neutral in reaction, but never acid. Cow's milk, 
[as it reaches the consumer, is always acid, so that it must be 
made alkaline by the addition of lime water before it is fit for 
the baby's use. 

The sugar in cow's milk (four per cent.) is normally much 
less than that in mother's milk (seven per cent.), and the addi- 
tion of water, necessary to bring the fat and proteids down to a 
proper amount, reduces the sugar to almost nothing, so that 
sugar must be added to give sufficient sweetness to the food. 

With " twelve per cent." milk as a basis, it is only necessary, 



PREPARATION OF FOOD. 



331 



in preparing food for an infant under three months of age, to 
add lime water, milk-sugar, and water in proper proportions. 
The amounts of lime water and sugar do not change at all, but 
the milk is increased and the water proportionately diminished 
from day to day as the child grows older and is able to take 
stronger food. 

Twenty ounces of food are made at each time, and for this 
amount one ounce each of lime water and milk-sugar are re- 
quired. When the amount of " twelve per cent." milk suited to 
the age of the child has been added, enough boiled water is 
poured in to make the total amount of food exactly twenty 
ounces and the work is done, thus : 





1 *-«' 




■3 % 


Result. 






•*& 


O.* 






. 


a. 


O -~ 


&£ 


Fat. 


Sugar. Proteids. 




Si 


i?i 


3i 


Up to .6o# 


5% 


. 20 </,, 


Second day. 






3H 


3 xx 1.20 # 


5% 


•4P% 


Third to fourth day. 






3 m 


1.80% 


6% 


.60% 


Fourth to seventh day. 






*iv 




2.40% 


6% 


.80% 


Seventh to thirtieth day. 






3v 




3- # 


6% 


I. % 


Second month. 






^vi 




3.60% 


6% 


1.20% 


Third month. 



It will be seen that the last formula in the above table, con- 
taining fat, 3.60 per cent. ; sugar, six per cent. ; and proteids, 
1.20 per cent., is nearly the same as that of mother's milk 
(fat, four per cent.; sugar, seven per cent.; proteids, two per 
cent.) ; and beginning at about the fourth month the infant is 
usually able to take milk of the latter strength. 

" Eight per cent." milk is used for making the 4-7-2 for- 
mula, merely because it is more easily managed than " twelve 
per cent." milk. Like " twelve per cent." milk, it may be made 
from gravity cream, from centrifugal cream, or from top milk. 



* If milk-sugar cannot be obtained, granulated sugar may be used in 
its place. One fruidounce or one Chapin dipperful of granulated sugar 
equals one ounce in weight. Milk-sugar is lighter, and one and one- 
half fluidounces or one and one-half dipperfuls are required to make 
one ounce in weight. 



332 



A NURSE'S HANDBOOK OF OBSTETRICS. 



From gravity cream, by adding two parts of 4-4-4 milk to 
one of gravity cream, thus : 



Fat. 


Sugar. 


Proteids 


16 


4 


4 


4 


4 


4 


4 


4 


4 



3)24 



From centrifugal cream, by adding three parts of 4-4-4 milk 
to one of centrifugal cream, thus : 



Fat. 


Sugar. 


Proteids 


20 


4 


4 


d 


4 


4 


4 


4 


4 


4 


4 


4 


)32 


16 


16 



From top milk, by removing with the Chapin dipper sixteen 
ounces of top milk from the full bottle. 

To modify " eight per cent." milk for the infant it is only 
necessary to dilute it one-half with boiled water, which reduces 
the formula to fat, four per cent. ; sugar, two per cent. ; proteids, 
two per cent. ; and then add five per cent, of sugar, which raises 
that ingredient to seven per cent. (5 + 2). 

In preparing twenty ounces of food the exact formula is as 
follows : 







00 « 




Result. 


Age. 


■3 


Fat. 


Sugar. 


Proteids. 


3i 


£i 3* 


3« 


4% 


7% 


2$ 


Fourth to ninth mouth. 



One ounce of sugar to twenty of food is, of course, exactly 
five per cent, (one in twenty), and as one ounce of lime water 
is used, only nine of water are needed to bring the total quan- 
tity up to twenty ounces. 



AMOUNT AT EACH FEEDING. 333 

Having prepared the food properly, according to the age of 
the child, the next point is to ascertain how much is to be given 
at each feeding and how frequently the child is to be fed. 

The hours for feeding are to be exactly the same as those 
for nursing at the breast, given on page 313, and the amount 
to be fed at each meal-time is as follows : 

Second day. One-half to one ounce. 

Third to thirtieth day One to three ounces. 

Second month Three to four ounces. 

Third month Four to five ounces. 

Fourth to ninth month Five to six ounces. 

It will be seen that, until the baby is about three weeks old, 
twenty ounces of food will last throughout the entire twenty- 




Fig. 170.— The " Sloane Maternity" measuring-glass. 



four hours, but after this time it will be necessary to prepare 
twice the quantity, some of which will, at first, have to be thrown 
away. This double amount may be prepared at one time, or, if 
fresh milk is served twice daily, half may be prepared in the 
morning and the other half at night. Usually it is best to prepare 
the entire amount of food for the twenty-four hours at one time 
and keep it on ice until it is wanted. Food should never be 
kept over from one day to another, but a fresh supply should 
be made up each morning. 



334 A NURSE'S HANDBOOK OF OBSTETRICS. 

A convenient method of preparing milk in accordance with 
the foregoing formulae will be found in the use of the Sloane 
Maternity Milk Set,* arranged by Dr. Edwin B. Cragin, of 
New York, and consisting of a measuring-glass (Fig. 170) and 
a Chapin dipper (see Fig. 169). 

The apparatus is used as follows : 

1. Pour into the glass granulated sugar or milk-sugar up 
to the proper mark as indicated on the side. 

2. Add one dipperful (one ounce) of lime water and mix 
by shaking the glass. 

3. Add the required number of dipperfuls (ounces) of 
" twelve per cent.," or " eight per cent." milk according to the 
age of the child as already explained. 

4. Fill the measuring-glass up to the top graduation (marked 
" 20 oz. of food") with plain boiled water, barley-water, or oat- 
meal-water. 

During the first month plain water is best, but afterwards 
barley-water may be used or oatmeal-water if the infant is very 
constipated. 

Barley-water may be made of the whole barley or of bar- 
ley flour as follows. From whole barley: Add two teaspoonfuls 
of washed pearl barley to a pint of water ; boil down slowly to 
two-thirds of a pint and strain. From barley Hour: Put two 
tablespoonfuls of barley flour into a quart saucepan with one 
and one-half pints of water; boil down slowly to one pint. 
Strain and allow the liquid to set to a jelly. When warmed 
for use it will return to a liquid. 

Oatmeal- water is made as follows : Add one tablespoon- 
ful of well-cooked oatmeal to a pint of water; allow it to sim- 
mer slowly for an hour or two until a smooth mixture is ob- 
tained. Strain. 

It is to be distinctly understood that the problem of feeding 
an infant on artificial nourishment is often a most difficult one, 



* The Sloane Maternity Milk Set is manufactured and sold by 
James T. Dougherty, 409-411 West Fifty-ninth Street and 334 East 
Twenty-sixth Street, New York City. 



BOTTLES AND NIPPLES. 



335 



and that the nurse must never attempt any important modifica- 
tions of diet on her own responsibility, but report at once to the 
physician any unfavorable symptoms that may arise. 

The next question to be considered is the method of adminis- 
tering the food. It is, of course, to be taken from a bottle 
through a rubber nipple, and the selection of a proper nursing- 
bottle and nipple are matters of no small importance. 

The shape of the bottle should be such that every part of the 
inner surface can be reached with a swab or brush (Fig. 171). 




3— 
2 — 

1 — 




Fig. 171. — Nursing-bottles. A, 



improper pattern, with long, slender neck 
pattern, without neck. 



B, proper 



Bottles with sharp angles or broad shoulders should never be 
used, for it is impossible to clean them properly, and milk is 
very apt to collect and sour in their many nooks and corners. 

The bottle should be graduated so that it need only be filled 
to the amount proper for a given feeding, and so that it will be 



336 



A NURSE'S HANDBOOK OF OBSTETRICS. 



possible at all times to tell exactly how much food the infant has 
taken. 

The best nipples are the plain ones of black rubber, but the 
most important point in the selection of a nipple has to do with 
the size of the hole through which the milk is to come. The hole 
is usually too large, and it is often best to buy nipples without 
any holes at all and make them of the required size with a needle. 

The test consists in holding the bottle, filled with milk and 
with the nipple attached, upside down (Fig. 172). The milk 







«. 








— 1 








- 








— I 








— 












r^. 




— 8 


— 










































~ 


crt 


— fr 


— 




UJ 














— 







- 


— 


Z 


— S 


_E 


- 


D 






~ 


O 




■—, 




Fig. 172. — Testing size of opening in nipple. Milk should drop out as indicated, and 
not flow in a stream. 

should escape drop by drop, and if it runs out in a stream the 
hole is too large. The objection to the large hole is that the 
child nurses too rapidly, and develops indigestion, colic, and 
other disorders. 

The care of the bottles and nipples is another matter of the 
greatest importance, for if any sour milk is allowed to collect 
it will promptly sour fresh milk whenever it is used. 



CARE OF NURSING BOTTLES. 337 

There should be as many bottles and nipples in commission 
as there are feedings in the twenty-four hours, so that no bottle 
will be used more than once in any day. 

As soon as a nipple has been used it is to be washed thor- 
oughly inside and out with castile soap and hot water, and a 
needle or bristle passed through the hole in the end to force out 
an}" little curd which may have lodged there. It is then put in 
a cup containing fresh saturated solution of boric acid. Once 
daily all the nipples are to be boiled for fifteen minutes. 

There should be two cups of boric acid solution, and in the 
morning all the nipples, freshly cleaned and sterilized, are placed 
in one. Afterwards, as the nipples are used, and after they have 
been washed, they are placed one by one in the other cup until 
all are transferred, when they are again boiled and made ready 
for the next day. Fresh solution should be used each day, and 
the cups must be covered with saucers or napkins to keep out 
dust and other foreign matter. 

The bottles, as has been said, must be so modelled that every 
part of the interior can be reached with a brush or swab. After 
each feeding the bottle is to be washed with castile soap and hot 
water and wiped inside and out, so that no vestige of milk or 
milkiness remains. It is then rinsed thoroughly with fresh 
water and placed on end to drain. Once in every twenty-four 
hours all the bottles are to be boiled. To prevent breakage they 
should be filled with cold water and placed in a vessel containing 
cold water, which is then brought to a boil. After boiling vigor- 
ously for not less than fifteen minutes the vessel is taken from 
the fire and allowed to cool until the bottles can be removed 
without scalding the hand. To attempt to cool them by the 
addition of cold water would be sure to crack some, if not all. 

When the baby is fed, it must be supported in a comfortable 
position, and the bottle is always to be held by the mother or 
nurse in such a way that the nipple will be full of milk. The 
child should never be put to bed with the nipple in its mouth, 
and, as in breast feeding, it should never be allowed to dawdle 
over its meal. If a fair trial shows that it is not anxious for 
its food, the bottle should be taken away and not offered again 



338 A NURSE'S HANDBOOK OF OBSTETRICS. 

until the next meal time. If the infant persistently refuses to 
take its food there is usually something wrong with the milk, 
and the physician should be consulted. 

Only the proper amount of modified milk for one feeding 
should be put in the bottle, and it should then be warmed to 
body temperature by placing the bottle in a vessel of hot water. 
In cold weather a piece of warm flannel may be wrapped around 
the bottle to keep the milk from growing cold towards the end 
of the feeding. Under ordinary circumstances, a normal child 
should take the entire quantity of food prepared for one feeding, 
and if any is left over at the end of the meal it should be thrown 
away and never returned to the main supply. 

As a rule, city milk of good quality is so carefully cared for 
from the time it is milked until it reaches the consumer that, if 
put on ice at once, it will keep sweet for the entire twenty-four 
hours, but in very hot weather, or when the food has to last for 
a journey of several days, the milk will turn sour, even on 
the ice. 

In such cases it becomes necessary to treat it in a way which 
will destroy the germs of fermentation and so keep the milk 
sweet. This is done by heating the milk to such a degree of 
temperature that the fermentative organisms will be destroyed. 
This, in its most primitive form, is accomplished by the familiar 
process of " scalding" the milk, so commonly done by poor 
people who buy cheap milk which is so old that it is just at the 
turning-point when they get it. 

Sterilization is a process which was once in great vogue for 
preserving milk for the use of infants. This consists in placing 
the milk in a " sterilizer" (Fig. 173) and surrounding it with 
live steam for a definite period of time, which raises the tem- 
perature to 212 F. It is true that sterilization destroys all the 
germs in the milk and keeps it sweet for a long period, but it 
has the disadvantage not only of altering the taste to a decided 
degree, but of making the product much more indigestible than 
" raw" milk. On this account milk is not sterilized as much as 
formerly, for under ordinary circumstances it is safer to take the 
slight risk of infection from the comparatively small number 



STERILIZATION AND PASTEURIZATION. 339 

of bacteria to be found in good milk than to subject the child to 
the greatly increased difficulties of digesting sterilized milk. 




STERILIZING CHAMBER 




Fig. 173.— Steam sterilizer. (Arnold.) 





Fig. 174.— Freeman pasteurizer. 



Another reason, however, has done more than anything else to 
do away with the use of sterilized milk, and this is the discovery 






340 A NURSE'S HANDBOOK OF OBSTETRICS. 

that if the milk is subjected for a considerable period of time 
to a temperature of 167 F. (instead of 212 F.) it will be suffi- 
ciently " sterilized" for all practical purposes, without under- 
going any alteration in taste or increase in indigestibility. 

This process is known as pasteurization, and is accom- 
plished as follows : 

The " pasteurizer" * (Fig. 174) is a large tin or copper pail 
with a cover, containing a rack which holds the nursing bottles. 
The rack consists of a number of water-tight cylinders, each 
large enough to admit a bottle, and the pail is so constructed that 
the rack may rest on the bottom and the cover be tightly ad- 
justed, or, with the cover off, the rack may be raised up and 
secured in such a way that the tops of the bottles are about two 
inches above the top of the pail. 

The bottles are those to be used for the feedings, and are 
graduated in ounces and half-ounces. As many bottles as there 
are to be feedings in the twenty-four hours are filled with prop- 
erly prepared milk up to the proper graduation mark, so that 
each bottle will contain one feeding and no more. They are 
then stoppered with ordinary cotton wadding (not absorbent cot- 
ton) and placed in the cylinders. Cold water is poured in each 
cylinder around the bottle, and any empty cylinders are filled 
with water. Each cylinder is to be filled, and the water should 
not be colder than runs from the faucet. 

The pail, without the rack and bottles, is now filled with 
water up to the rim on the inside and set on the stove to boil. 
As soon as it is boiling furiously it is removed from the fire 
and set on the table or floor, but never on iron or stone, which 
would abstract the heat too rapidly. 

The rack and bottles are lowered at once to the bottom of the 
pail, the cover adjusted snugly, and the apparatus left undis- 
turbed for three-quarters of an hour exactly. 

At the end of this time the pail is placed in the kitchen sink 

* The Freeman Pasteurizer is manufactured and sold by James T. 
Dougherty, 409-411 West Fifty-ninth Street, and 334 East Twenty-sixth 
Street, New York City. 



DRUGS EXCRETED BY MILK. 341 

or in some other convenient place, the rack raised up and secured 
so that the tops of the bottles will be above the top of the pail, 
and cold water allowed to run in and out, around the cylinders 
and overflowing the sides of the pail, until the milk is thoroughly 
cool. 

The bottles are now placed on ice, and as each feeding time 
comes round, one is taken, the cotton stopper removed, the 
nipple attached, and the contents warmed for the infant's use. 

This milk should be used the same day that it is prepared, 
but it will keep sweet for three or four days. 

In general, " raw" milk is better for the baby than milk that 
has been " cooked," and the nurse should never suggest ster- 
ilization or pasteurization on her own responsibility, but consult 
the physician if such a process seems to be indicated. 

When, for any reason, it is necessary to remove the child 
from the breast, and the glands are still secreting milk, it will 
be necessary to " dry up" the milk. As a rule, the physician will 
give directions for this, but it occasionally falls to the lot of the 
nurse to attend to the matter herself. 

The breasts should be emptied as completely as possible, 
either by massage or with the breast-pump, the ingestion of 
fluids restricted to the smallest amount consistent with ordinary 
comfort, and the snuggest kind of a breast-binder applied and left 
undisturbed for three or four days. There should never be any 
fever, or pain in the breasts, but when the binder is removed the 
glands will be found somewhat hard and lumpy. This should 
disappear in the course of two or three days more, and the 
breasts appear soft and free from any trace of milk. 

Drugs excreted by the Milk. — The Journal of the Ameri- 
can Medical Association (November 1, 1902) publishes the fol- 
lowing list of drugs which are excreted by the milk and which, 
consequently, affect the infant: Sulphur, rhubarb, senna, jalap, 
indigo, arsenic, bismuth, iron, mercury, potassium iodide, zinc, 
iodine, antimony, opium, oil of anise, oil of dill, garlic, castor 
oil, lead, oil of turpentine, oil of copaiba, all the volatile oils, 
magnesium sulphate (Epsom salt), carbolic acid, quinine, strych- 
nine, and cascara sagrada. The article goes on to say, " The 



342 



A NURSE'S HANDBOOK OF OBSTETRICS. 



elimination of these drugs by the milk is more liable to take 
place when the mother is in a disturbed condition physically and 
when the mammary glands are not in a normal condition. Con- 
sequently care must be observed in prescribing some of these 
preparations for the mother. For example, copaiba and turpen- 
tine will so affect the taste of the milk as to cause the infant to 
refuse the breast. Diarrhoea may be produced in the infant by 
administering castor oil or other of the above purgatives to the 
mother, and the opium preparations will produce the opposite 
effect on the child through the mother's milk. It is said that 
sufficient action may be produced on the child by administering 
mercury, arsenic, and potassium iodide to the mother." 



XXVI 

Maternal Impressions and the Control of Sex 

By a " maternal impression" is understood an effect on the 
physical development of an unborn infant due to some shock, 
fright, accident, or other profound nervous strain sustained by 
the mother during the course of her pregnancy. 

The possibility of phenomena of this kind is believed by a 
great number of individuals, among whom may be counted many 
of the highest intelligence, and children are frequently seen with 
birth-marks, harelips, supernumerary fingers or toes, and other 
deformities and disfigurements of various types, all of which are 
attributed to some form of nervous impression from which the 
mother suffered during the period of gestation. 

It is safe to say, however, that the supposed connection be- 
tween these unfortunate occurrences and any mental state of 
the mother may be traced to coincidences, or to the imagination, 
in every case, and the nurse should be informed on this subject 
in order that she may be able to reassure such expectant mothers 
as may be apprehensive that their children will be " marked." 

The effects of heredity must not be confused with the subject 
under discussion, and it must be borne in mind that certain traits 
and characteristics and certain diseases may be transmitted from 
the mother to her unborn child. Also, a mother who is in a 
markedly debilitated condition, or one who is given to excesses 
of any kind, such as the habitual use of alcohol, morphine, or 
other drugs, cannot be expected to give birth to a healthy, robust 
infant, and, for this reason, such a parent may be the mother of 
a deformed, disfigured, or partially developed child. 

Maternal impressions, however, are to be considered as sup- 
posedly affecting the physical development of the child as a 
result of a sudden profound shock transmitted entirely from 
without. 

While, perhaps, it cannot be said that this is an absolute im- 

343 



344 



A NURSE'S HANDBOOK OF OBSTETRICS. 



possibility, it may be stated with the utmost positiveness that 
such an effect can occur no more easily before the birth of the 
infant than after it is in its mother's arms. 

It will be remembered that the ovum in which the foetus 
develops is nothing more than an egg of a peculiar kind, and 
that the child within it is, from the very first, an absolutely inde- 
pendent organism developing by itself, and not connected in any 
very intimate way with the mother. There is no mingling of 
the fetal and maternal blood-currents, and the blood of the 
foetus merely gives up its waste products and takes on oxygen 
in the placenta as does that of the mother in her lungs. 

The placenta is merely a thickened area in the sac formed 
by the amnion and chorion, and the whole may be regarded as 
the shell (soft, to be sure) of the egg in which the child is being 
formed. It is true that the placental structure penetrates to a 
certain depth into the tissues of the uterine wall, but it can no 
more be regarded as part of the maternal organism than can the 
roots of a tree be considered as part of the earth into which they 
extend. 

Moreover, the umbilical cord, which is the only direct attach- 
ment of the foetus to the placenta, is absolutely devoid of nerves, 
and no matter how much the placenta may be- regarded as part 
of the mother, it is clear that there is no actual nerve connection 
whatever between the two. 

In a word, the ovum, with its contained foetus, merely finds 
in the uterus a suitable nest for its development, and it is a fact 
that, except for the practical difficulties in the way, no mother 
is absolutely necessary to the development of her child after 
conception has occurred. If we could solve the practical prob- 
lem of transferring the fertilized ovum from the oviduct or 
uterus of one woman to that of another, the process of develop- 
ment would go on just the same, much as a hen's egg may be 
hatched by any hen or even in a purely mechanical incubator. 

That this statement is not idle speculation is proved by the 
fact that, in Edinburgh within the last few months, two im- 
pregnated ova from a rabbit were transplanted to the oviduct 
of another rabbit of entirely different breed, and this second 



MATERNAL IMPRESSIONS. 345 

rabbit eventually gave birth to two rabbits of the first variety, 
together with several others of her own kind. It should be 
said in explanation that both rabbits were impregnated at the 
same time by males of their own breeds, respectively, in order 
that the oviduct and uterus of the rabbit to whom the ova were 
to be transferred should be in exactly the necessary stage of 
gestational development. 

Thus it will be seen that the connection between a foetus 
and its mother is practically no more intimate before birth, while 
it lies in, and absorbs its nourishment from, her uterus, than after 
delivery, when it rests upon, and takes its nourishment from, 
her breast ; and that the opportunity for nerve impulses to pass 
from one to the other is equally impossible in either case. 

The question of the possibility of controlling the sex of 
unborn infants so that parents may beget male or female chil- 
dren at will has received much attention of late, and the nurse 
will often be interrogated in this connection. 

The most recent teaching goes to show that, for the present 
at least, this is a matter entirely beyond the power of the human 
mind. None of the many theories and methods that have been 
advanced from time to time has proved in any way reliable, and 
where results may seem to have been secured the probability 
of coincidence must always be enough to overthrow any positive 
conclusions. 






KEY TO PRONUNCIATION 

Note that c and g have always their true historical sounds, the 
so-called " hard," as in rat and go. 



a as in ask, fast, chant. 

a as in far, arm, calm. 

a as in sofa, America, particular. 

a as in hat, mat, man. 

a as in bare, hare, fair. 

a as in American, republican. 

e as in regime, prostrate, usage, 
e as in fete, fate, eight 
e as in met, men, head. 
e as in there, where, bear. 
e as in fern, earth, bird. 
e as in billet, cornet, added. 

i as in piano, medial, studio, 
i as in pique, machine, meet. 
i as in pit, pin, begin. 
i as in pier, peer, dear, 
l as in spirit, necessity. 

o as in obey, potato, biological. 

6 as in no, node, soul. 

o as in actor, adductor. 

o as in not, odd, what. 

b as in form, broad, fall. 

o as in atom, gallop. 

6 as in German Gothe, gotter. 



u as in instrument, prudential. 
u as in rule, prudent, move, 
u as in pwll, could, book, 
u as in bz*rn, co/onel. 
u as in but, bud, come, 
ii as in German Muller, griin, 
French jus. 

ai as in aisle, isle, bite. 

au as in Faust, how, now. 

iu as in neutrality, emulate. 

iu as in feud, few, stupid. 

oi as in oil, coin, hoy. 

c (hard)=k as in eat, &ing,ehasm. 

ch as in loch, German koch. 

cw = qu as in oween, guit. 

dh = th as in thine, this, smooth. 

g (hard) as in go, gallon. 

hw = wh as in where, when. 

j as in /aw, judge, edge. 

ng as in siwg, bank. 

n (French) as in ton, boh. 

s as in son, sit, city. 

sh as in shall, machine, motion. 

th as in thin, breath. 

tsh as in church, much, witch. 

z as in £one, music. 

zh as in a^ure, cohesion. 



347 



GLOSSARY 

Note. — The definitions and pronunciations, in this Glossary are 
taken, in the main, from Lippincott's Medical Dictionary. The refer- 
ences to illustrations refer to cuts and other figures in the body of the 
book. 

Abdomen (ab-do'm^n). The belly. 

Abdominal (ab-dom'f-nal). Belonging to or relating to the abdomen. 

A. Delivery, delivery of the child by abdominal section. See 

Cesarean Section. 
A. Gestation, ectopic pregnancy occurring in the cavity of the 

abdomen. 
A. Pregnancy. See Abdominal Gestation. 
A. Section. See Cesarean Section, Cceliotomy, Laparatomy. 
Abnormal (ab-ndr'mal). Contrary to the usual or natural structure; 

contrary to the natural condition. 
Abortifacient (a-bor-tt-fe'sh^nt). i. Causing miscarriage. 2. A drug 

capable of causing a miscarriage. 
Abortion (a-bor'shon). The expulsion of the foetus which is not viable; 

expulsion of the foetus during the first three months of pregnancy. 
Abrasion (ab-re'zhon). 1. The fretting or rubbing off of a patch of skin 
or other covering. 2. A spot rubbed bare of the skin or nearly so. 
3. Denudation by means of chemical action, or by a destructive 
disease-process. 
Abscess (ab's^s). A collection of pus contained in a cavity formed in 
any part of the body by the disintegration and stretching of the 
tissue. 
Acid (as'z'd). 1. Sour, sharp to the taste. 2. Having the chemical prop- 
erties of an acid. 
Acid (as'id). In chemistry, a compound having the property of com- 
bining with an alkali or a base and thus forming a new compound. 
A. Reaction, a reaction by which litmus paper or solution is 
turned red by the addition of an acid. 
Acme (ac'mi). The highest degree or height of a disease; crisis. 
Accouchement (a-cush-moh'). [French, accoucher, to put to bed, to 
deliver.] The act of being delivered; delivery. 

A. Force, rapid delivery, artificially performed ; as in cases of 
eclampsia or placenta praevia. 

349 



350 GLOSSARY. 

Accoucheur (a-cu-shcr'). [French.] A male midwife ; an obstetrician. 

Accoucheuse (a-cu-sh£z'). [French.] A midwife. 

Acute (a-ciut'). Sharp-pointed; ending at a point or in an angle less 
than a right angle ; severe, as acute pain. In medicine the term is 
applied to diseases having violent symptoms attended with danger 
and terminating within a few days. 

Adnexa (ad-ncc'sq.). Appendages. 

Uterine A., the Fallopian tubes and ovaries. (Fig. n.) 

After-birth (after-berth). The structures cast off after the expulsion 
of the foetus, including the membranes and the placenta with the 
attached umbilical cord; the secundines. (Figs. 21 and 22.) 

After-pains (af ter-penz). Those pains, more or less severe, after ex- 
pulsion of the after-birth, which result from the contractile efforts 
of the uterus to return to its normal condition. 

Albolene, Alboline (al'bo-lin). An oily substance resembling white 
vaseline. 

Albuminuria (al-biu-rm-niu'ri-aj. An albuminous state of the urine. 

Alimentation (arz'-men-te'shon). The act of taking or receiving nour- 
ishment. 

Alkaline (al'ca-lain or -lin). Having the properties of an alkali. 

A. Reaction, the reaction in which red litmus paper is turned 
blue by alkalies. 

Alvine (al'vm or al'vain). Belonging to the belly, stomach, or intestines. 
A. Dejections, the faeces. 

Amenorrhcea (a-men-o-ri'g.). Absence or stoppage of the menstrual 
discharge. 

Amnion (am'ni-on). The most internal of the fetal membranes, con- 
taining the waters which surround the foetus in utero. 

Amniotic (am-ni-ot'ic). Pertaining to the amnion. 

A. Sac, the " bag of membranes" containing the foetus before 
delivery. 

Anemia, Anemia (a-ni'mi-aj. Deficiency of blood in quantity, either 
general or local ; also, deficiency of the most important constituents 
of the blood, especially the red blood-corpuscles. 

Anemic, Anemic (a-nem'ic). In a state of anaemia. 

Anesthesia, Anesthesia (an-es-thi'zi-aj. 1. Loss ^f feeling or per- 
ception, especially loss of tactile sensibility. 2. The production of 
anaesthesia. 

Anesthetic, Anesthetic (an-es-thef ic). 1. Having no perception or 
sense of touch. 2. A medicine having the power of rendering the 
recipient insensible to pain. 

Anesthetist, Anesthetist (an-es'thi-ttst). A person who administers 
an anaesthetic. 

Anchylosis (ang-d-16'sis). See Ankylosis. 



GLOSSARY. 351 

Ankylosis (ang-cM6'sis). The consolidation of the articulating sur- 
faces of two or more bones that previously formed a natural joint; 
stiff joint. 
Ante-partum (an"ti-par'tum). Before delivery or childbirth. 
Anterior (an-ti'ri-or). Situated before or in front of. 
Antiseptic (an-ti-s^p'tz'c). 1. Preventing sepsis or putrefaction. 2. A 
substance which prevents or retards putrefaction, — that is, the de- 
composition of animal or vegetable bodies with evolution of offensive 
odors. Among the principal antiseptics are : alcohol, creosote, car- 
bolic acid, common salt, corrosive sublimate (bichloride of mercury), 
vinegar, sugar, charcoal, chlorine, boric acid, tannic acid, and benzole. 
A. Dressing, a surgical dressing containing antiseptics. 
A. Surgery, surgery with proper antiseptic precautions. 
Anus (e'nus). The external opening of the rectum. 

Areola (a-ri'o-lg.). The ring of pigment surrounding the nipple. (Fig. 36.) 
Secondary A., a circle of faint color sometimes seen just outside 
the original areola about the fifth month of pregnancy. 
Arterial (ar-ti'ri-al). Belonging to an artery. 

A. Blood, the bright red blood of the arteries which has been 

aerated (charged with oxygen) in the lungs. 
A. Hemorrhage, hemorrhage directly from an artery. 
Artery (ar'te-ri). Any one of the vessels by which the blood is con- 
veyed from the heart to the organs and members of the body. (So 
called because they were supposed by the ancients to contain air.) 
Articular (ar-tfc'iu-laj). Relating to joints. 

Articulation (ar-t/c-iu-le'shon). The fastening together of the various 
bones of the skeleton in their natural situation; a joint. The articu- 
lations of the bones of the body are divided into two principal 
groups, — synarthroses, immovable articulations, and diarthroses, 
movable articulations. 
Ascites (a-sai'tiz). An accumulation of serous fluid in the peritoneal 

cavity; dropsy of the peritoneum; dropsy of the belly. 
Asepsis (a-s^p'szs). The absence of septic materials; exclusion of dis- 
ease germs and other causes of septic poisoning. 
Aseptic (a-s<?p'tic). Not septic; free from septic matter; not exposed 

to the injurious effects of septic materials. 
Asphyxia (as-fzc'si-a). Suspended animation; that state in which 
there is total suspension of the powers of body and mind, usually 
caused by interrupted respiration and deficiency of oxygen in the 
blood, as by hanging or drowning. 

A. Neonatorum, A. Neophitorum, " asphyxia of the new-born," 
deficient respiration in new-born children. 
Aspirating Needle (as'pi-re-tmg). A hollow needle attached to a suc- 
tion syringe for withdrawing fluid from the body. (Fig. no.) 



352 GLOSSARY. 

Assimilate (o-stm'i-let). To convert food into nutriment. 
Astringent (as-trin'jent). I. Binding; contracting. 2. A medicine 

having the power to check discharges, whether of blood, of mucus, or 

of any other secretion. 
Atrophic (a-troi'ic). Relating to atrophy; characterized by atrophy or 

failure of nutrition. 
Atrophied (at'ro-fid). Affected with atrophy ; wasted. 
Atrophy (at'ro-fO- Defect of nutrition; wasting or emaciation with 

loss of strength, unaccompanied by fever. 
Axilla (ac-sil'aj. The armpit. 

Bacteria (bac-ti'ria.). The plural of bacterium. A form of microbes 

or vegetable micro-organisms. 
Basiotribe (be'si-o-traib). An instrument for crushing the base of the 

fetal skull. (Fig. 96.) 
Basiotripsy (be'si-o-tnp-st). The crushing of the base of the fetal skull 

with the basiotribe. 
Bimanual (bai-man'iu-al). Performed with or relating to both hands. 
B. Palpation, examination of the pelvic organs of a woman by 
placing one hand on the abdomen and the fingers of the other 
in the vagina. 
Birth (berth). 1. The act of coming into life; the delivery of a child. 
2. That which is born. See Delivery. 

B. Mark, a " maternal mark" or " mother's mark," a mark on 
the skin from birth, — the effect, as some erroneously sup- 
pose, of the mother's lcnging for, or aversion to, particular 
objects, or of some accidental occurrence affecting her own 
person during pregnancy. 
Bladder (blad'cr). The urinary bladder; a thin distensible sac with 
membranous and muscular walls, situated in the anterior part of the 
pelvic cavity and acting as a reservoir for the urine secreted by the 
kidneys. 
Bland (bland). [Latin, blan'dus, agreeable.] Mild, soothing. 
Bougie (bu'jz or bu-zhe'). A slender instrument primarily designed for 

introduction into the urethra. (Fig. 101.) 
Breech (britsh). The nates or buttocks. 

B. Labor or B. Delivery, labor or delivery marked by breech 
presentation. (Fig. 49.) 

Cesarean Operation, Cesarean Section (si-ze'ri-an). [From Julius 
Caesar, — said to have been born this way ; more probably from Latin 
cce'dere, to cut.] The operation of cutting into the womb through 
the walls of the abdomen and removing a child when natural delivery 
is impracticable or impossible. 



GLOSSARY. 353 

Capillary (cap'Me-n or ca-pil'a-ri). i. Resembling a hair in size. 
2. Pertaining to a fine hair-like tube ; pertaining to a capillary ves- 
sel. 3. One of the minute blood-vessels which form a net-work 
between the terminations of the arteries and the beginnings of the 
veins. 
Caput (ce'put, Latin, ca'put). 1. The head, consisting of the cranium, 
or skull, and the face. 2. Any prominent object, like the head. 
C. Incuneatum, impaction of the head of the foetus in labor. 
C. Succeda'neum, a dropsical swelling which appears on the pre- 
senting head of the foetus during labor, caused by lack of 
pressure on that part. (Fig. 159.) 
Carbohydrate (car-bo-hai'dret). Any one of a group of chemical com- 
pounds, most of which are the sugars and starches and important 
elements of food. 
Caries (ce'ri-iz). [Latin, "rottenness."] 1. Ulceration of bone. 2. 

Decay of the teeth resulting in the formation of cavities. 
Cartilage (car'tz-lej). 1. Gristle,— a pearly white, glistening substance 
adhering to the articular surfaces of bones and forming parts of the 
skeleton. 2. Any organ or part of an organ made up of this material. 
Exsiform C. See Ensiform. 
Casein (ce'si-m). The most important of the proteids of milk; con- 
stituting the basis of cheese in a state of purity. 
Cathartic (ca-thar'tic). 1. Purging or purgative. 2. A medicine which 
quickens or increases evacuations from the intestines, or produces 
purging. 
Catheter (cath'e-tir). A surgical instrument like a tube, closed, but 
with one or more perforations towards the closed extremity, for 
passing into canals or passages, — used especially by introduction into 
the bladder through the urethra for the purpose of drawing off the 
urine. (Fig. 118.) 
Caul (col). A portion of the amniotic sac which occasionally envelops 

the child's head at birth. 
Cell (sd). 1. Literally, a " cellar" or " cavity;" hence, any hollow space. 
2. One of the minute masses of protoplasm of which organized 
tissue is composed. 
Cephalic (s^-fal'fc). Belonging to the head. 

C. Pole, the cephalic extremity of a foetus. 

C. Presentation, presentation of any part of the fetal head in 
labor. (Figs. 41, 44, and 48.) 
Cephalotomy (sef-a-lot'o-mi). Dissection of the head; also the cutting 

or breaking down of the fetal head. 
Cephalotribe (s^fa-lo-traib). An instrument for crushing and extract- 
ing the fetal head in cases of difficult labor. 

23 



354 GLOSSARY. 

Cephalotripsy (sef'a-lo-trtp'si). The operation of crushing the fetal 

head with the cephalotribe. 
Cerebrospinal (ser"i-bro-spai'nal). Relating to the cerebrum and the 
spinal cord. 

C. Fluid, the clear, limpid fluid contained in the ventricles of 
the brain, the subarachnoid spaces and the central canal of 
the spinal cord. 
Cervix (ser'vix). The neck, more particularly the back part; also 
applied to those parts of organs that are narrowed like a neck. 

C. Uteri, the neck of the uterus ; the lower and narrower end 
of the uterus. (See Fig. 12.) 
Chloasma (clo-az'maj. PI. chloasmata. A cutaneous affection exhibit- 
ing spots and patches of a yellowish-brown color. The term chlo- 
asma is a vague one and is applied to various kinds of pigmentary 
discolorations of the skin. 

C. Gravidarum, C. Uterinum, chloasma occurring during preg- 
nancy. 
Chorea (co-ri'aj. St. Vitus's dance; a convulsive disease characterized 
by irregular and involuntary movements of the limbs. It usually 
occurs in early life and affects girls more frequently than boys. 
Chorion (co'ri-on). The second, or most external, of the fetal mem- 
branes. 
Chromicized Catgut (cro'mi-saizd). Catgut treated with chromic acid 

for use as ligatures or sutures. 
Chronic (cron'ic). Long continued; lasting a long time; opposed to 

acute. 
Cicatricial (sic-a-tn'sh'al). Of the nature of, or relating to, a cicatrix. 
Cicatrix (si-ce'trix). PI. cicatrices. A scar; an elevation or seam con- 
sisting of a new tissue formation replacing tissue lost by a wound, 
sore, or ulcer. 
Circulatory (s^r'ciu-le-to-n)- Relating to, or affecting, the circulation. 
C. System, the system of the animal body consisting of the 
heart, arteries, capillaries, and veins, through which the 
blood circulates. 
Climacteric (clai-mac-t<?r'ic or clai-mac'tc-ric). A particular epoch of 
the ordinary term of life, marked by periods of seven years, at which 
the body is supposed to be peculiarly affected and to sniffer consid- 
erable change ; especially, the menopause or grand climacteric. The 
menopause or " change of life." 
Clitoris (clit'o-ris). A small, elongated, erectile body at the anterior 

angle of the vulva. (See Fig. 8.) 
Clonic (clon'zc). Applied to spasms in which the contractions and 

relaxations are alternate. 
Coagulated (co-ag'iu-le-ted). Clotted. 



GLOSSARY. 355 

Coaptation (co-ap-te'shon). The fitting together of the ends of a frac- 
tured bone or the edges of a wound. 

Cceliotomy (si-li-ot'o-rro). Abdominal section; surgical opening of the 
abdominal cavity. 

Collapse (co-laps'). I. A falling or caving in. 2. A state of extreme 
depression or complete prostration of he vital powers, such as 
occurs after severe injury or excessive bleeding. 

Colostrum (co-los'trum). A substance in the first milk after delivery, 
giving to it a greenish or yellowish color. 

C. Corpuscles, large, granular cells found in colostrum. 

Colpeurynter (ccd-piu-rm'tir) . A dilatable bag, used to stretch the 
vagina by introducing the bag in a flaccid condition and then dis- 
tending it by the forcible injection of air or water. 

Colpeurysis (col-piu'n'-sis). Dilatation of the vagina by means of a 
colpeurynter. 

Coma (co'ma.). A state of lethargic drowsiness, produced by compres- 
sion of the brain and other causes. 

Comatose (co'ma-tos). 1. Having a constant propensity to sleep; full 
of sleep. 2. Relating to coma. 

Conc^tion (con-sep'shon). The impregnation of the female ovum by 
the semen of the male, whence results a new being. 

Congenital (con-jerii-tal). Born with a person; existing from or from 
before birth, as, for example, congenital disease, a disease originating 
in the foetus before birth. 

Congestion (con-j^s'tshon). An excessive accumulation of the contents 
of any of the blood-vessels or ducts. 

Conjunctiva (con-jungc-tai'vaj. The delicate mucous membrane lining 
the eyelids and covering the external portion of the eyeball. 

Conjunctival (con-jungc-tki'val). Pertaining to the conjunctiva. 

Conjunctivitis (con-jungc-tz-vai'tw). Inflammation of the conjunctiva. 

Constriction (con-stn'c'shon). A contraction or stricture; that which 
constricts. 

Contraindication (con"tra^m-df-ce'shon). That which forbids the use 
of a remedy which otherwise it would be proper to exhibit. Any 
condition of disease which renders some special line of treatment or 
some particular remedy undesirable or improper. 

Convalescence (con-va-\es'ens). The state or period between the re- 
moval of actual disease and the full recovery of the strength. 

Convalescent (con-va-\es'ent) . Returning to full health after a disease 
is removed. 

C. Diet, a diet for convalescing patients consisting of any light, 
simple, and appetizing food. 

Convulsion (con-vul'shon). Violent agitation of the limbs or body, 
generally marked by clonic spasms. 



356 GLOSSARY. 

Cornea (c<5r'ni-aj. The transparent structure forming the anterior part 
of the eyeball. 

Coronal (cor'o-nal). Belonging to, or relating to, the crown of the 
head. 

C. Suture, the suture formed by the union of the frontal bone 
with the two parietal bones. (See Fig. 27.) 

Couveuse (cu-wz'). An arrangement or apparatus designed for the 
preservation and development of infants prematurely born or other- 
wise feeble. An incubator (Fig. 151), which term is in more 
common use in the United States. 

Cranioclasis, Cranioclasm (cre-ni-o-cle's/s, cre'ni-o-clazm). The 
crushing of the fetal skull. 

Cranioclast (cre'ni-o-clast). An instrument used in effecting cranio- 
clasis. (Fig. 95.) 

Craniotomy (cre-ni-ot'o-nu)- The opening of the fetal skull when nec- 
essary to effect delivery. 

C. Scissors, strong S-shaped scissors for use in craniotomy. 
(Fig. 100.) 

Crotchet (crotsh'et). A curved instrument for extracting the foetus 
after craniotomy. No longer used. 

Curd (curd). The coagulum which separates from milk upon the addi- 
tion of acid, rennet, or wine. It consists of casein with most of the 
fatty elements of the milk. 

Curettage (ciu-r^t'ej). The act of using a curette. 

Curette (ciu-rrt')- [French.] 1. A sort of scraper or spoon used in 
removing granulations, foreign bodies, incrustations, etc., from the 
walls of normal or other cavities in the body. Most commonly used 
for removing diseased tissue or foreign matter such as retained pla- 
cental tissue from the walls of the uterus. (Fig. 135.) 2. To use a 
curette. 

Curettement (ciu-rct'm^nt). Same as Curettage. 

Cutaneous (ciu-te'ni-us). Belonging to the skin. 

Cutis (ciu'tfs). The skin, consisting of the cutis vera and the epi- 
dermis. Also, the cutis vera, or true skin. 

Cyanosis (sai-a-no'sis). A blue color of the skin resulting from con- 
genital malformation of the heart from some defect of the 
pulmonary circulation by which the venous blood is not wholly 
oxygenated. 

Cyanotic (sai-a-not'/c). Relating to cyanosis; affected with cyanosis. 

Decapitation (di-cap-i-te'shon). The removal of the head of the foetus 
in embryotomy. 

Decidua (di-sid'iu-aj. The membranous structure produced during ges- 
tation and thrown off from the uterus after parturition. It consists 



GLOSSARY. 357 

of the greatly changed uterine mucous membrane and the fetal 
envelopes. 

D. Reflexa, that portion of the decidua which is reflected over 

and surrounds the ovum. 
D. Serotina, " late decidua," that portion of the decidua vera 

which becomes the maternal part of the placenta. 
D. Vera, that portion of the decidua which lines the interior of 
the uterus. (Fig. 19.) 
Decomposition (di-com-po-zisWon) . 1. The separation of compound 
bodies into their constituent parts or principles ; analysis. 2. Putre- 
factive decay. 
Delirium (di-hr'z-um). A derangement of the functions of the brain 
characterized by incoherent and wandering talk, illusions, and un- 
steady gait. 
Delivery (di-1/v'cr-t). [French, delivrer, to free, to deliver.] 1. The 
expulsion of a child by the mother, or its extraction by the obstetric 
practitioner. 2. The removal of a part from the body ; as delivery 
of the placenta. 
Denudation (d<?n-iu-de'shon). The laying bare of any part of an animal 
or plant ; the stripping off of the integument, whether by a surgical 
or by a pathological process. 
Denuded. Laid bare. 
Diagnosis (dai-ag-no'sis). The art or science of signs or symptoms by 

which one disease is distinguished from another. 
Diagnostic (dai-ag-nos'tfc). 1. Relating to diagnosis. 2. Distinctive; 

of sufficient value to enable one to make a diagnosis. 
Diaphoresis (dai"a-fo-ri'szs). A state of perspiration; profuse per- 
spiration ; sweat. 
Diaphoretic (dai"a-fo-r<?t'ic). 1. Causing perspiration. 2. A medicine 

having the power to produce diaphoresis. 
Diathesis (dai-atrrV-sis). A particular habit or disposition of the body 
which renders it peculiarly liable to certain diseases ; constitutional 
predisposition. 
Diet (dai'<?t). The food proper for invalids. Also, the regulation of 
food to the requirements of health and the cure of disease. 
D. -Sheet, a written or printed dietary. 
Dietary (daiV-te-n). A system or course of diet; a regulated allowance 

of food given to each person daily. See Diet-Sheet. 
Dietetic (dai-^-t^t'ic). Belonging to the taking of proper food, or to 
diet. 

D. Treatment, treatment of disease by careful and scientific 
regulation of the diet. 
Differential (d*f-<?-r<?n'shal). Making a difference; showing a differ- 
ence ; distinguishing. 



358 GLOSSARY. 

D. Diagnosis, the determining of the distinguishing features of 

a malady when nearly the same symptoms belong to two 

different classes of disease, as in gout and rheumatism or 

epilepsy and eclampsia. 

Dilute, Diluted (dai-liut', dai-liu't<?d). Mixed, weak; reduced in 

strength ; rendered weaker by the addition of water. 
Disintegration (dis-m-ti-gre'shon). The separation of the integrant 

parts or particles of a body. 
Diuresis (dai-iu-ri'sz's). Increased discharge of urine, from whatever 

cause. 
Diuretic (dai-iu-r<?t'/c). i. Belonging to diuresis; causing diuresis. 

2. A medicine which increases the flow of urine. 
Dropsy (drop'sz). The accumulation of serous fluid in the tissues or in 

the thorax or abdomen. 
Duct. A tube or canal by which a fluid is conveyed. 
Ductus (duc'tus). A duct. 

D. Arteriosus, " arterial duct," a blood-vessel peculiar to the 
foetus, communicating directly between the pulmonary artery 
and the aorta. (See Figs. 28 and 29.) 

D. Venosus, " venous duct," a blood-vessel peculiar to the foetus, 

establishing a direct communication between the umbilical 
vein and the descending vena cava. (See Figs. 28 and 29.) 
Dysmenorrhgea (dts-m£n-o-ri'c|). Difficult and painful menstruation. 
Dyspnoea (dis-pni'aj. Difficult or labored breathing. 
Dystocia (dzs-to'si-aj. Difficult, slow, or painful birth or delivery. It 
is distinguished as Maternal or Fetal according as the difficulty is 
due to some deformity on the part of the mother or on that of 
the child. 

Placental D., difficulty in delivering the placenta. 

Eclampsia (<?c-lamp'si-^). Any epileptiform seizure, especially recurrent 
convulsions, not immediately due to disease of the brain. 

Puerperal E., a convulsive attack coming on in women during 
or after labor and due probably to uraemia. 
Ectopic (ec-top'ic). Out of place. 

E. Gestation, gestation in which the foetus is out of its normal 

place in the cavity of the uterus. (Fig. 34.) See Extra- 
uterine Pregnancy. 
E. Pregnancy, same as Ectopic Gestation. 
E. Sac, the amniotic sac in ectopic gestation. 
Eczema (ec'ze-ma). A superficial affection of the skin characterized bj 
a smarting eruption of small vesicles, generally crowded together, 
without fever, and not contagious. 
Eczematous (^c-z^m'a-tus). Belonging to or affected with eczema. 



GLOSSARY. 359 

Eliminate (i-l/m'/-net). To put out or expel; to throw off or set free. 

Elimination (i-h'm-*-ne'shon). The act of expelling from the body as 
waste products. 

Eliminative (i-ltm't-ne-ttv). i. Tending to increase elimination or ex- 
cretion. 2. Any agent or remedy that promotes excretion. 

Emaciation (i-me-shi-e'shon). The state of being or becoming lean. 

Embolism (c?m'bo-l/zm). The obstruction of an artery or a vein by a 
clot of coagulated blood, or by any body brought from some point 
away from the site of obstruction. See Embolus and Thrombus. 
Air E., embolism in which the obstruction consists of air-bubbles. 

Embolus (<?m'bo-lus). A piece of blood-clot which has been formed in 
the larger vessels in certain morbid conditions and has afterwards 
been forced into one of the smaller arteries so as to obstruct the 
circulation. 

Embryo (^m'bri-6). The product of conception in utero before the end 
of the third month of pregnancy; after that it is called the foetus. 
(Fig. 24.) 

Embryotomy (cm-bri-ot'o-mi). The destruction or separation of any 
part or parts of the foetus in utero when circumstances exist to 
prevent delivery in the natural way. 

Emetic (i-m<?t'/c). 1. Having the power to excite vomiting. 2. A 
medicine which causes vomiting. 

Emmenagogue (e-meria-gog). A medicine having the power to promote 
the menstrual discharge. 

Emulsion (i-mul'shon). An oily or resinous substance suspended in 
water through the agency of mucilaginous or adhesive substances. 
Milk is a natural and perfect emulsion. 

Emunctory (i-mungc'to-n). 1. Excretory. 2. Any excretory duct of 
the body. 

Enema (erie-mq.). A medicine to be thrown into the rectum; a clyster; 
a rectal injection. 

Enervation On-£r-ve'shon). Weakness; languor; lack of nerve stimulus. 

Ensiform (erisi-iorm). Like a sword; sword-shaped. 

E. Appendix, Cartilage, or Process, the extremity of the ster- 
num or breast-bone. 

Epidemic (ep-i-dem'ic). 1. A term applied to any disease which seems 
to be upon the entire population of a country at one time, as distin- 
guished, on the one hand, from sporadic disease (or that which 
occurs in isolated cases) and, on the other, from endemic disease 
(or that which is limited to a particular district). 2. An epidemic 
disease ; the season of prevalence of any epidemic disease. 

Epilepsy (ep'i-\ep-si) . The falling sickness; a chronic non-febrile 
nervous affection, characterized by seizures of lo-.s of consciousness, 
with tonic or clonic convulsions ("fits"). The ordinary duration of 



360 GLOSSARY. 

a fit is from five to twenty minutes. The frequency of the attacks 
or fits varies immensely; m some cases they occur daily and in 
others at intervals of ten years or more. 

Epileptic (ep-i-lep'tic). I. Belonging to epilepsy. 2. A person affected 
with epilepsy. 

Epileptiform (ep-i-lep'ti-iorm) . Like epilepsy. 

Episiotomy (ep"i-sa.i-ot'o-mi) . Surgical or obstetrical incision of the 
vulvar orifice. 

Ergot (er'got). A drug having the remarkable property of exciting pow- 
erfully the contractile force of the uterus, and chiefly used for this 
purpose, but its long-continued use is highly dangerous. Usually 
given in the fluid extract. Dose, gss-ii. 

Ergotin (er' go-tin). The extract of ergot or active principle of ergot. 
Dose, V15 to y 2 grain. 

Ergotole (er'gd-td\). A proprietary preparation of ergot said to possess 
double the strength of the official fluid extract. Dose, ^ss-i. 

Erosion (i-ro'zhon). An eating or gnawing away: similar to ulceration. 

Evacuation (i-vac-iu-e'shon). 1. The act of discharging the contents of 
the bowels, or defecation. 2. The discharge itself; a dejection or 
stool. 

Evisceration (i-vis-e-re'shon) . Taking the bowels or viscera out of the 
body. 

Obstetric E., removal of the abdominal or thoracic viscera of 
the foetus in embryotomy. 

Exacerbation (?g-zas-£r-be'sh<5n). 1. An increased force or severity 
of the symptoms of a disease. 2. The stage or time of periodical 
aggravation in certain fevers. 

Excoriation (Vcs-co-ri-e-shon). Abrasion or removal, partial or com- 
plete, of the skin. 

Excrement (^cs'cri-ment). Originally, anything that is excreted: 
usually applied to the alvine faeces. 

Excrementitious (Vcs"cri-m£n-tish'us) . Belonging to excrement. 

Excrete (<?cs-crit'). To separate from the bodily tissues useless matter 
which is to be cast out of the system. 

Excretion (Vcs-cri'shon). 1. The separation of those fluids from the 
blood which are supposed to be useless, as urine, perspiration, etc. 
2. Any such fluid itself. 

Exostosis (cc-sos-to'sis). An exuberant growth of bony matter on the 
surface of a bone. 

Expiration (<?cs-p?-re'shon). The act of breathing out or expelling air 
from the lungs. 

Expiratory (<?cs-pair'e-to-ri). Relating to or of the nature of expiration. 

Expire (<?cs-pair'). 1. To expel the breath; to breathe out. 2. To die. 

Expulsive (ecs-pvYsiv). Tending towards, promoting, or causing ex- 
pulsion. 



GLOSSARY. 361 

E. Pains, labor-pains occurring during the expulsive stage and 

accomplishing the expulsion of the foetus. 
E. Stage, that stage of labor which follows complete dilatation 
of the uterine cervix, during which the expulsion of the 
foetus takes place; the second stage of labor. 
Exsanguination (^c-sang-gui-ne'shon) . The state of being without 

blood. 
Extension (Vcs-t^n'stum). The reverse of flexion. 

Extravasation (^cs-trav-a-se'shon). The escape of any fluid of the 
body, normal or abnormal, from the vessel, cavity, or canal that 
naturally contains it, and its diffusion into the surrounding tissues. 
Extra-uterine (ecs-tr^-iu't^-nn). Outside of the uterus. 
E. Life, life after birth. 

E. Pregnancy, pregnancy in which the foetus is contained in 

some organ outside of the uterus. (Fig. 34.) 

F^ces (fi'siz). The alvine excretions or excrement. The matter ex- 
pelled from the bowels at stool. 

Fallopian (fa-16'pi-an). [Relating to G. Fallopius, a celebrated Italian 
anatomist of the sixteenth century.] 

F. Tubes, the oviducts, — two canals extending from the side of 

the fundus uteri to the ovaries. (Fig. 11.) 
F. Pregnancy, pregnancy occurring in the Fallopian tubes, — 
same as tubal pregnancy. (Fig. 34.) 
Febrile (fi'bn'l, or feb'ril). Belonging to fever; feverish. 
Fecal (fi'cal). Relating to fseces : containing faeces. 
Fecundation (fec-un-de'shon). The act of impregnating or the state of 
being impregnated ; the fertilization of the ovum by means of the 
male seminal element. 
Fenestrated (fen-^s-tre'ted). Pierced with openings. 
Fetus (fi'tus). The same as Foetus. The spelling fetus is preferable 
from a linguistic point of view ; but the other is far more common 
in professional literature. 
Fillet (fil'et). A noose for making traction on the foetus in difficult 

labor. Never used now. 
Finger Cot. A thin rubber covering for the finger to protect it from the 
air or from septic discharges. Occasionally used as a dressing to 
cover a slight wound or abrasion of the finger. 
Fissure (fish'iur). A crack or narrow opening. 
Flex (fiVx). To bend, as a joint or a jointed limb. 
Flexion (fiVc'shon). The act of bending; the state of being bent. 

F. Stage, that stage of labor in which the head of the foetus 
bends forward. 
Foetus (fi'tus). The child in utero from the end of the third month of 



362 GLOSSARY. 

pregnancy till birth. (See Fig. 25.) During the first three months 
the product of conception is known as the embryo. 

Fontanel, Fontanelle (fon-ta-nd'). The quadrangular space between 
the frontal and two parietal bones in very young children. This is 
called the anterior f. and is the familiar " soft spot" just above a 
baby's forehead. A smaller, triangular one {posterior /.) sometimes 
exists between the occipital and parietal bones. 

Foramen (fo-re'm^n). A hole, opening, aperture, or orifice, — especially 
one through a bone. 

F. Ovale, an opening situated in the partition which separates 
the right and left auricles of the heart in the foetus. 

Forceps (for'seps). An instrument consisting of two arms which can be 
approximated and used for grasping a part. (Figs. 76, J7, 78, and 79.) 

Formula (for'miu-la). 1. A short form of prescription in practice in 
place of the more full instruction in the Pharmacopoeia. 2. A concise 
mode of indicating by symbols the chemical constituents of a com- 
pound or the result of chemical changes. 

Fornix (for'm'cs). PI. fomices. An arch; any vaulted surface. 

F. of the Vagina, the angle of reflection of the vaginal mucous 
membrane onto the cervix uteri. 

Fourchette (fur-sh^t'). [French, "fork."] The posterior angle or 
commissure of the labia majora. 

Friable. Easily reduced into small pieces. 

Function (fungc'shon). A power or faculty by the exercise of which 
the vital phenomena are produced; the special office of an organ in 
the animal or vegetable economy. 

Fundus (fun'dus). The base or bottom of any organ which has an 
external opening considered as the top. 

F. Uteri, the base of the uterus, which is to be considered as 

upside down with the top (os) pointing downward. (See 
Fig. 12.) 
Funis (fhYm's). A cord, — especially the umbilical cord. 

Galactagogue (ga-lac'ta-gog). 1. Causing the flow of milk. 2. Any 

drug which causes the flow of milk to increase. 
Gastric (gas'tn'c). Belonging to the stomach. 
Genital {)en'i-ia\). 1. Belonging to generation. 2. Relating to the 

genital organs. 
Genltpectoral (j<?n-iu-p<?c'to-rol). [Latin, ge'nu, knee, + pec'tus, 

breast] Relating to the knees and chest. 

G. Position, that posture in which the patient rests on the knees 

with the thighs upright, the head and upper part of the chest 
being on the table or bed. The knee-chest position. (Fig. 
107.) 



GLOSSARY. 363 

Germicidal (j£r'mi-sai-dal). Destroying germs. 

Germicide (jrr'rru-said). A substance which has the power of destroy- 
ing micro-organisms. 

Gestation (jVs-te'shon). The condition of a pregnant female; preg- 
nancy ; gravidity. 

G. Sac, the sac enclosing the embryo in ectopic pregnancy. 

Gland (gland). An organ consisting of blood-vessels, absorbents, and 
nerves, for secreting or separating some particular fluid from the 
blood. 

Glandular (glan'diu-lar). Pertaining to or like a gland in appearance, 
function, or structure ; also, furnished with glands. 

Glans (glanz). An acorn-shaped organ. 

G. Clito'ridis, the bulbous extremity of the clitoris. 
G. Pe'nis, the nut-like head or end of the penis. 

Graafian Follicles or Vesicles (graf'i-an). Small spherical bodies in 
the ovaries, each containing an ovum. (Fig. 15.) 

Granulation (gran-iu-le'shon). The process by which little grain-like, 
conical fleshy bodies form on ulcers and suppurating wounds, filling 
up the cavities, and bringing nearer together and uniting their edges. 
2. One of the bodies thus formed. 

Gravid Uterus (graved). The uterus in the impregnated state or during 
gestation. 

Gravidity (gre-vid'i-ti) . The condition of a woman who is pregnant; 
gestation ; pregnancy. 

Gynecic, Gynecic (ji-ni'sic). Relating to the female sex or to women. 

Gynaecologist, Gynecologist (jm-i-col'o-jzst). One who is skilled in 
gynaecology. 

Gynaecology, Gynecology (jm-i-col'o-ji). A treatise on woman and the 
peculiarities of her constitution as compared with man ; the science 
which treats of the female constitution and particularly of the dis- 
eases and injuries of the female genital organs. 

Hemorrhage, Hemorrhage (hem'o-rej). Escape of the blood from its 
natural channels; bleeding. 

Hemorrhoid, Hemorrhoid (h^m'o-roid). A pile; a vascular tumor im- 
mediately within (internal h.) or just outside of (external h.) the 
anus. Hemorrhoids are termed blind when they do not cause hemor- 
rhage and bleeding when they do. 

Hernia (h£r'-ni-aj. the displacement, through an abnormal opening, of 
an organ or tissue, most commonly of a portion of the intestine from 
the cavity in which it is naturally contained ; a " rupture." 

Hydrometer (hai-dromV-tir). An instrument for ascertaining the spe- 
cific gravity of fluids. 

Hygiene (hai'ji-in). That department of medicine which has for its 
direct object the preservation of health or the prevention of disease. 



364 GLOSSARY. 

Hygienic (hai-ji-^n'ic). Belonging to hygiene. 
Hypersecretion (hai"p£r-si-cri'shon). Excessive secretion. 
Hypertrophy (hai-p^r'tro-fi)- Enlargement of a part or an organ, espe- 
cially when due to over-nutrition. 
Hypodermatic, Hypodermic (hai"po-d£r-mat'ic, hai-po-der'rmc). 1. Con- 
nected with the application of medicine under the skin ; subcuta- 
neous. 2. A medicine introduced under the skin. 

H. Injection, an injection beneath the skin of drugs or nutrient 

solutions. 
H. Needle, the hollow needle forming the nozzle of a hypo- 
dermic syringe. 
H. Syringe, a small syringe with a fine-pointed nozzle for in- 
jecting fluids under the skin. 
Hypogastric Arteries. Same as the umbilical arteries which accompany 

and form part of the umbilical cord. 
Hysteria (hzs-ti'ri-a). A functional disease often observed in young 
unmarried women, in which there may be a simulation of almost any 
disease and a great lack of self-control. 

Iliac (*Ti-ac). Belonging to the ilium or the flanks. 

I. Artery, either of two arteries, right and left, given off from 

the abdominal aorta and dividing to form the external and 

internal iliac arteries on each side of the body. 

I. Fossa, a broad and shallow cavity at the upper part of the 

inner surface of the ilium. 

Ilium (iTi-um). PI. il'ia. The haunch bone; the broad, flat, upper 

portion of the innominate bone. (Fig. 1.) 
Impregnation (rni-pr^g-ne'shon). The act of making, or state of being 

pregnant ; fecundation. 
Incise (in-saiz'). To cut, as with a knife. 
Incised Wound (m-saizd' wund). A wound made by a sharp cutting 

instrument. 
Incision (m-szzh'on). A wound made by cutting, — especially an opera- 
tion-wound. 
Incubator (m'ciu-be-tor). See Couvcuse. 

Indurate, Indurated (m'diu-ret, -re-t^d). Made hard; hardened. 
Induration (in-diu-re'shon). The state or process of hardening of the 
tissues from any cause ; the hardening of any part from the effect 
of disease ; any part or tract of abnormally hardened tissue. 
Infection (m-f<?c'sh5n). 1. The communication of a disease by personal 
contact with the sick or by means of effluvia arising from the body 
of the sick ; contagion. 2. The agent by which a communicable 
disease is conveyed ; a contagium. 

Septic I., infection caused by septic germs. See Septic. 



GLOSSARY. 365 

Infectious (m-f^c'shus). Capable of extension by infection; con- 
tagious ; easily communicated. 
Inflammation (m-fla-me'shon). A state of disease characterized by 

redness, pain, heat, and swelling, attended or not with fever. 
Infusion (m-fiu'zhon). To pour in or upon. In surgery the injection 
of hot normal salt solution ( 6 /i per cent.) into a blood-vessel. 
Venous I., when the injection is made into a vein. 
Arterial I., when the injection is made into an artery. 
Subcutaneous I., when the injection is made into the subcu- 
taneous connective tissue, usually under the breast, over the 
shoulder-blade, or in the outer side of the thigh. (Fig. 111.) 
Ingest (in- jest'). To throw in, or put in, as food into the stomach. 
Ingesta (m-jVs't^). Food taken into the body by the mouth. 
Ingestion (m-jVs'tshon). The act of putting or taking food into the 

stomach. 
Inhalation (m-he-le'shon). A drawing of the air into the lungs; the 

inspiring of medicated or poisonous fumes with the breath. 
Insomnia (m-som'ni-aj. Want of sleep; wakefulness; chronic or 

habitual privation of sleep. 
Innominate (i-nom'i-net). Having no name; unnamed. 

I. Bone, the hip-bone, composed of the ilium, ischium, and os 
pubis. (Fig. 1.) 
Innominatum (t'-nom-i-ne'tum). The innominate bone. (Fig. 1.) 
Inspiration (m-spi-re'shon). The act of drawing in the breath. 
Inspiratory (m-spai're-to-n). A term applied to muscles which by their 
contractions increase the dimensions of the chest and thus produce 
inspiration. 
Intertrigo (m-tir-trai'go). An excoriation or galling of the skin about 
the anus, axilla, or other part of the body, with inflammation and 
moisture. 
Intestine (in-tes'tin). The long membranous tube, continuing from the 
stomach to the anus, in the cavity of the abdomen ; the bowels or 
entrails. 
Inunction (m-ungc'shon). The act of rubbing in an ointment, or 
simply of anointing. This is a method of applying certain substances 
to the cutaneous surface, the object being to promote their absorption. ' 
In utero. Inside the uterus. 

Inversion (m-wr'shon). A turning upside down, inside out, or end for 
end. 

I. of the Uterus, the state of the womb being turned inside 
out, caused by violently drawing away the placenta before it 
is detached by the natural process of labor. (Fig. 105.) 



366 GLOSSARY. 

Involution (m-vo-liu'shon). i. A rolling or pushing inward. 2. A 
retrograde process of change the reverse of evolution : particularly 
applied to the return of the uterus to its normal size and condition 
after parturition. 

Irrigation (ir-i-ge'shon). 1. The continual application of water or of 
a lotion on an affected part; the washing out of a cavity by a 
stream of water. 2. The liquid used in washing out a cavity or a 
wound. 

Ischium (/s'ci-um). The posterior and inferior bone of the pelvis, dis- 
tinct and separate in the foetus or the infant; or the corresponding 
part of the innominate bone in the adult. (Fig. 1.) 

Jaundice (jan'dzs, or jondzs). Yellowness of the skin, eyes, tissues, 
and secretions generally from impregnation with bile-pigment ; 
icterus. 

Knee-chest Position. See Genupcctoral Position. 

Labia (le'bi-a). The nominative plural of labium. Lips or lip-like 
structures. 

L. Majora, the folds of skin containing fat and covered with 

hair which form each side of the vulva. 
L. Minora, the nymphae, or folds of delicate skin inside of the 
labia majora. (Fig. 8.) 
Labor (le'bor). Parturition; the process by which a foetus is separated 
and expelled from its mother. 

Dry L., when there is a lack of amniotic fluid. 

Induced L., when brought on by outside interference. 

Missed L., when the normal processes cease and the foetus is 

retained. 
Precipitate L., when of abnormally short duration. 
Premature L., when occurring before the normal time. 
Spontaneous L.. when without any assistance. 
Laceration (las-c-re'shon). The act of tearing; a rent or torn place 

in any tissue ; a wound made by tearing. 
Lactation (lac-te'shon). The act or period of giving suck; the secretion 

of milk ; the time or period of secreting milk. 
Lacteal (lac'ti-al). Resembling or relating to milk. 

L. Calculus, a concretion of thickened milk occurring in the 

breast. 
L. Swelling, swelling of the breast from accumulation cf milk 
due to obstruction of the lacteal ducts. 
Lactiferous (lac-tzf'e-rus). Practically the same as lacteal. 



GLOSSARY. 367 

Lactometer (loc-tom'r-trr). An hydrometer for determining the specific 

gravity of milk. 
Lambdoid, Lambdoidal (lam'doid, iam-doi'dal). Having the shape of 
the Greek letter A 

L. Suture, the suture between the occipital and two parietal 
bones. (See Fig. 27.) 
Laparotomy (lap-a-rot'o-m?*)- Cutting into the abdominal cavity through 

the flank ; less correctly, abdominal section at any point. 
Larynx (lar'mgcs). That portion of the air-passages between the base 

of the tongue and the windpipe. 
Laxative (loc'sa-U'v). 1. Slightly purgative or aperient; mildly cathar- 
tic. 2. A laxative medicine. 
Lesion (li'zhun). A hurt, wound, or injury of a part; a pathological 

alteration of a tissue. 
Lethargic (k-thar'jfc). Belonging to lethargy; in a state of lethargy. 
Lethargy (lcth'aj-ji). A state of marked drowsiness, stupor, or sleep 

which cannot easily be driven off. 
Leucorrhcea (liu-co-ri'a). A whitish discharge from the female genital 

organs ; the whites. 
Ligature (h'g'a-tshur). A thread or cord used for tying around an 

artery, vein, or any growth. 
Linea (lm'i-a). PI. lines. A line or thread. 

L. Alba, the central tendinous line extending from the pubic 

bone to the ensiform cartilage. 
Line^: Albicantes, shining whitish lines upon the abdomen 
caused by pregnancy or distention ; striae gravidarum. 
(Fig. 30.) 
Liquor (lzc'or, or lai'cwor). A liquid. 

L. Amnii, the fluid contained within the amnion in which the 

foetus floats. 

Lithotomy Position (h'-thot'o-rcu). The position of a patient flat on 

the back with legs and thighs flexed and thighs separated widely; 

also called the dorso-sacral posture. (Fig. 126.) 

Lochia (16'ci-aJ. The discharge from the genital canal during several 

days subsequent to delivery. 
Lochial (16'ci-al). Relating to the lochia. 
Lying-in (lai"mg-m'). The puerperal state. 
L. Fever, puerperal fever. 

L. Hospital, a hospital where pregnant women are cared for 
before, during, and after labor. 

Malaise (mal-ez'). [French, mal, ill, + aise, ease.] Discomfort or un- 
easiness ; indisposition. 

Malposition (mal-po-zish'on). An abnormal position, as of the foetus; 
a displacement. (See Fig. 50.) 



368 GLOSSARY. 

Malpractice (mal-pnzc'Us). Practice contrary to good judgment, 
whether from ignorance, carelessness, or a wrong motive. 

Mamma (mam'aj. PI. mamma. ["Ma-ma," the instinctive cry of an 
infant.] The breast of the human female. (Fig. 14.) 

Mammary (mam'a-ri). Belonging to the mamma, or female breast. 

Mania (me'ni-q.). A form of insanity marked by an exalted but per- 
verted mental activity. 

Maniacal (me-nai'o-col). Affected with mania ; resembling mania. 

Manual (man'iu-al). Relating to, or performed by, the hands. 

Massage (ma-sazh'). The systematic therapeutical use of rubbing, 
kneading, stroking, slapping, straining, pressure, and other passive 
exercises applied to the muscles and accessible parts. 

Maternal (me-tcr'nal). Relating to or originating with the mother. 

Maternity (me-ter'nl-ti). 1. Motherhood; the condition of being a 
mother. 2. A lying-in hospital. 
M. Nurse, an obstetric nurse. 

Meatus (mi-e'tus). A passage; an opening leading to a canal, duct, or 
cavity. 

M. Urinarius, the external orifice of the urethra. (Fig. 8.) 

Meconium (mi-co'ni-um). The dark-green or black substance found in 
the large intestine of the foetus or newly born infant. 

Median (mi'di-an). In the middle; between others; medial or mesial. 

Melancholia (md-an-co'li-aj. A form of insanity (and a condition of 
mind bordering upon insanity) in which there is great depression of 
spirits, with gloomy forebodings. 

Melancholic (me\-an-co\'ic). Belonging to melancholia. 

Membrane (m^m'bren). A skin-like tissue used to cover some part of 
the body, and sometimes forming a secreting surface. Mucous mem- 
branes line cavities and canals which communicate with the external 
air, as the nose, mouth, etc. Serous membranes line cavities which 
have no external communication, such as the pleural and peritoneal 
cavities. They have a smooth, glossy surface from which exudes a 
transparent serous fluid that gives to them their name. When this 
fluid is secreted in excess dropsy of those parts is the result. The 
word " Membranes" is also used to indicate the amniotic sac which 
surrounds the foetus. 

Menses (men'siz). [PI. of Latin mensis, month.] The periodical 
monthly discharge of blood from the uterus ; the catamenia. 

Menstrual (m^n'stru-al). Relating to. or caused by, the menses. 

Menstruate (m^n'stru-et). To have the catamenial flow; to have the 
" monthly flow." 

Menstruation (m^n-stru-e'shon). The monthly period of the discharge 
of a red fluid from the uterus ; the function of menstruating. It 
occurs from puberty to the menopause. 



GLOSSARY. 369 

Menopause (mcn'o-poz). The period at which menstruation ceases; 

the " change of life." 
Microscopic (mai-cro-scop'j'c). So minute that it can be seen only by 

means of a microscope. 
Midwife (jnzd'waif). A woman who delivers women with child; a 

female obstetrician. 
Miscarriage (m/s-car'ej). The expulsion of the foetus at any time 

between the third and sixth month of gestation. More generally 

used to indicate the expulsion of the foetus at any time up to the 

period of viability of the child. 
Moxs Veneris (monz ve'neris). The eminence in the upper and anterior 

part of the pubes of women. (Fig. 8.) 
Monster (mon'stir). A foetus born with a redundancy or deficiency, a 

confusion or transposition, of parts. For example, a child born 

with two heads or with but one eye. 
Monstrosity (mon-stros'T-ti) . A monster. 
Monthlies (munth'liz). The menses. 
Morbid (mdr'bid). Diseased or pertaining to disease. Morbid is used 

as a technical or scientific term in contradistinction to the term 

healthy. 
Morbidity, Morbility (mor-bid'i-ti, mor-biYi-ti) . 1. The condition of 

being diseased. 2. The amount of disease or illness existing in a 

given community ; the sick-rate. 
Mother's Mark. A nsevus ; a birthmark. 
Mucosa (miu-co'saj. A mucous membrane. 
Mucous, Mucose (miu'cus, miu'cos). Belonging to or resembling 

mucus ; covered with a slimy secretion or with a coat that is soluble 

in water and becomes slimy. 

M. Membrane. See Membrane. 
Mucus (miu'cus). The viscid liquid secretion of a mucous membrane. 
Multigravida (mul-tf-grav'i-daj. A woman who has been pregnant 

several times, or many times. 
Multipara (mul-tqp'a-ra,). A woman who has borne several, or many, 

children. 
Mummification (mum"i-fz-ce'shon). The shrivelling up and compres- 
sion of a dead foetus. 

N^vus (ni'vu^). A natural mark or blemish; a mole, a circumscribed 

deposit of pigmentary matter in the skin. 
Nates (ne'tiz). The buttocks. 
Nausea (no'shaj. Originally, sea-sickness. Any sickness at the stomach 

similar to sea-sickness. 
Navel (ne'wl). The umbilicus. 

N. String, the umbilical cord. 
24 



370 GLOSSARY. 

Nephritis (ne-irai'tis). Inflammation of the kidney. 

Neurotic (niu-rot'zc). Of or belonging to the nerves; nervous. 

Neutral (niu'tral). Neither one nor the other; indifferent. 

N. Reaction, a reaction which is neither acid nor alkaline. 
Nitrogenous (nai-trojV-nus). Containing nitrogen ; nitrogenized. 
Nodular (nod'iu-laj). Belonging to a nodule; having the form of a 

nodule. 
Nodule (nod'iul). A little node; a small rounded mass. 
Normal (nor'mal). Regular; without any deviation from the ordinary 

structure or function ; according to rule. 
Nutrient (niu'tri-ent). I. Nutritious; nourishing. 2. A nutritious sub- 
stance. 

N. Enema, an injection of nutrient fluid into the rectum for 
the purpose of maintaining the strength of the system when, 
for any reason, food cannot be taken into the stomach. 
Nutriment (niu'tn'-men't). Nourishment. 
Nutrition (niu-tn'sh'on). The assimilation or identification of nutritive 

matter to or with our organs. 
Nutritious (niu-tnsh'us). Nourishing; affording nourishment or 

nutrition. 
Nutritive (niu'tn-tz'v). Pertaining to nutrition; capable of repairing 
the waste of the body ; nutritious. 

N. Enema, same as Nutrient Enema. 

Obstetric, Obstetrical (ob-stet'ric, ob-st^t'n'-caj). Belonging to mid- 
wifery or obstetrics. 

Obstetrician (ob-st^-tn'sh'an). An accoucheur, or man-midwife; a 
practitioner of obstetrics ; one who is skilled in obstetrics. 

Obstetrics (ob-stet'ncs). [Latin, obstetrix, midwife.] The art of as- 
sisting women in child-birth and of treating their diseases during 
pregnancy and after delivery ; midwifery. 

Occiput (oc'si-put). The back part of the head. 

CEdema (i-di'mq.). A swelling from effusion of serous fluid into the 
cellular substance ; a dropsical swelling. 

Oligohydramnios (ol"i-go-hai-dram'ni-os). Deficiency of the amniotic 
fluid. 

Opacity (o-pas'T-ti) . 1. Incapability of transmitting light; the reverse 
of transparency. 2. Any defect in the transparency of the cornea, 
from a slight film to an intense whiteness. 

Organ (or'gan). A part of an animal or vegetable capable of perform- 
ing some act or office appropriate to itself, as, for example, the 
heart, the lungs, or the stomach. 

Os. Mouth. 

O. Externum (external os), the external opening of the canal 
of the cervix. 



GLOSSARY. 371 

O. Internum (internal os), the internal opening of the canal 

of the cervix. 
O. Uteri, "mouth of the uterus." (See Fig. 12.) 
Os. [PI. ossa.] A bone. 

O. Innominatum, the innominate bone. (Fig. 1.) 
Osmosis (os-mo'sts). The power or action by which liquids are impelled 

through a moist membrane and other porous partitions. 
Osteomalacia (os'^ti-o-ma-le'si-a). A disease marked by progressive 

softening of the bones from loss of their earthy constituents, so that 

they become flexible and fragile and unable to support the body. 

The disease affects adults, especially pregnant women, and is fre- 
quently fatal. 
Ova. Plural of ovum. 

Ovarian (o-ve'ri-an). Belonging to the ovary. 
Ovary (d'xa-ri). The sexual gland of the female in which the ova are 

developed. (Fig. 13.) There are two ovaries, one at each side of 

the pelvis. 
Oviduct (6'vf-duct). The Fallopian tube which conveys the ovum from 

the ovary to the uterus. (See Fig. 13.) » 
Ovisac (6'vi-sac). Same as Graafian Follicle. 
Ovulation (ov-iu-le'shon). The growth and discharge of an unimpreg- 

nated ovum, usually coincident with the menstrual period. 
Ovule (ov'iul). A "little egg." The ovum before its discharge from 

the Graafian follicle. 
Ovum (6'vum). 1. An egg, particularly a hen's egg. 2. The female 

reproductive cell. The human ovum is a round cell about V120 of an 

inch in diameter, developed in the ovary. (Fig. 23.) 
Oxytocic (oc-si-to'sic). 1. Accelerating parturition. 2. A medicine 

which accelerates parturition. 

Pack the Uterus. To tampon the uterus. See Tampon. 
Pallor (pal'or). Paleness; loss of color. 

Palpation (pal-pe'shon). [Latin, palpa're, to handle gently, to feel.] 
Examination by the hand or by touch ; manipulation of a part with 
the fingers for the purpose of determining the condition of the 
underlying organs. 

Obstetric P., palpation of the abdomen of the pregnant woman 
to determine the size, position, and presentation of the 
foetus. 
Palpitation (pal-pt-te'shon). Convulsive motion of a part: applied 
especially to the rapid action of the heart, whether caused by disease 
or by excitement. 
Papilla (pa-pil'aj [PI. papil'lcu.] Originally, a "pimple." Any minute, 
nipple-like eminence. 



372 



GLOSSARY. 



Parietal (pe-raiV-tal). Belonging to the parietes or walls of any 
cavity, organ, etc. 

P. Bones, the two quadrangular bones that form the transverse 
arch of the cranium. 

Paroxysm (par'oc-sizm). An evident increase of symptoms which after 
a certain time decline ; a periodical fit or attack ; the periodic fits or 
attacks which characterize certain diseases. 

Paroxysmal (par-oc-siz'mal). Relating to, or characterized by, par- 
oxysms ; .occurring in paroxysms. 

Parturient (par-tiu'ri-£nt). Bringing forth; child-bearing. 

P. Canal, the canal through which the foetus passes in child- 
birth : it consists of the uterus and vagina regarded as one 
canal. 
P. Woman, a woman about to give birth to a child. 

Parturition (par-tiu-nsh'on). Expulsion of the foetus from the uterus; 
also the state of being in child-bed ; labor. 

Paternal (pe-tir'nal). Relating to or originating with the father. 

Pathologic, Pathological (path-o-log'ic, -\og'i-ca\). Belonging to 
pathology ; morbid. 

Pathology (pa-thol'o-JO- The doctrine or consideration of diseases; 
that branch of medical science which treats of diseases, their nature 
and effects. 

Pelvimeter (pe\-vim' e-ter). An instrument for measuring the diameters 
and capacity of the pelvis. (Fig. 5.) 

Pelvimetry (pel-vim' e-tri). The obstetrical measurement of the pelvis. 
It may be performed with the hand (Digital p.) or with a pelvimeter 
(Instrumental p.). When the measurements are made on the outside 
of the body it is External p.; when within the vagina, Internal p.; 
and when both within the vagina and outside of the body, Com- 
bined p. (See Figs. 6 and 7.) 

Pelvis (pel'vis). [Latin, "basin."] The bony cavity forming the lowest 
part of the trunk. It is bounded behind by the sacrum and coccyx ; 
at the sides and in front by the ossa innominata. (Fig. 1.) 

Penis (pi'm's). The male organ of copulation. 

Perforator (p^r'fo-re-tor). An instrument for boring into the cranium. 
(Fig. 94-) 

Perineorrhaphy (per" i-m-or' a-fi) . Suture of the perineum; the oper- 
ation for the repair of lacerations of the perineum. 

Perineum (per-i-ni'um). The space between the genital organs and the 
anus. (See Fig. 9.) 

Periphery (pe-rii'e-ri). The circumference of a circle; the parts most 
remote from the centre. 

Peristalsis (p^r-i-stal'sis). The peculiar movement of the intestines 
and other tubular organs, like that of a worm in its progress, by 



GLOSSARY. 373 

which they gradually propel their contents. Peristalsis is produced 
by the combined action of circular and longitudinal muscular fibres. 

Peristaltic (pcr-i-staYtic). Relating to peristalsis. 

Peritoneal (p£r"*"-to-ni'ol). Relating to the peritoneum. 

Peritoneum (p<?r"z-to-ni'um). A strong serous membrane investing the 
inner surface of the abdominal walls and the viscera of the abdomen. 

Peritonitis (p<?r"i-to-nai'Us). Inflammation of the peritoneum; popu- 
larly, " inflammation of the bowels." 

Pernicious (p£r-m*sh'us). Baleful; deleterious; highly dangerous : as 
pernicious anaemia, or pernicious vomiting. 

Perspiration (per-spi-reshon). [Latin, perspira're, to breathe every- 
where.] i. Sweat. 2. The process or function of sweating. 

Pessary (p<?s'a-ri). An instrument, usually in the form of a ring or a 
ball, for introduction into the vagina, to prevent or remedy the 
prolapse of the uterus. 

Phantom (fan'tom). The small effigy of a child used to illustrate the 
progress of labor. 

P. Pregnancy, feigned, hysterical, spurious, or false pregnancy; 

pseudocyesis. 
P. Tumor, a tumor of the abdomen due to flatus or contraction 
of the abdominal muscles. 

Pharmacopoeia (far"ma-co-pi'a.). An authoritative book containing a 
description of the medicines and drugs in use in a country. The 
United States Pharmacopoeia is published by authority once in ten 
years, after it has been revised by a national convention of physicians 
and pharmacists. 

Phenomenon (fi-nomV-non). PI. phenomena. An appearance; any- 
thing remarkable. In pathology it is synonymous with symptom. 

Phlegmatic (fiVg-mat'ic). Dull; sluggish; cold; morose; not easily 
excited. The oppositie of nervous when applied to one's disposition. 

Physical (fiz'i-cal). Belonging to nature. 

Physiological (ffz"i-o-loj'i-cal). Belonging to physiology. 

Physiology (ftz-i-ol'o-ji). The doctrine of vital phenomena, or the 
science of the functions of living bodies. 

Physique (fi-zic'). Natural constitution; corporeal form; personal 
endowments ; the physical or exterior parts of a person. 

Pigment (pig'ment). I. Any dye or paint. 2. The normal coloring- 
matter of the organs and fluids of the body. 

Pigmentary (pig'men-te-ri). Relating to pigment. 

Pigmentation (pzg-m^n-te'shon). The formation or deposition of pig- 
ment. 

Pipette (pi-pet'). A tube used in withdrawing or adding small quan- 
tities of fluid ; used chiefly in chemical and pharmaceutical work. 



374 GLOSSARY. 

Placenta (ple-s^n'taj. The circular, flat, vascular structure in the 
impregnated uterus forming the principal medium of communication 
between the mother and the child. (Figs. 21 and 22.) 

P. Previa, that condition in which the placenta is situated inter- 
nally over the mouth of the womb, often proving a cause 
of excessive hemorrhage (Fig. 35.) 
Pledget. A little plug. A wad of lint, cotton, or the like, applied as to 
a wound or a sore to keep out the air, absorb discharges, or retain 
a dressing. 
Plethora (pl<?th'o-raJ. A condition characterized by fulness of the 
blood-vessels, strong heart action and pulse, florid complexion, and 
general plumpness of the body. 
Plethoric (pli-tho'nc, or pkth'o-nc). Relating to plethora; full of 

blood. 
Pleura (plu'raj. A serous membrane, divided into two portions and 

lining the right and left cavities of the chest or thorax. 
Pleural (plu'ral). Relating to the pleura. 
Podalic (po-dal'zc). By means of or relating to the feet. 

P. Version, version by which the feet of the child are made to 
present. (See Fig. 71.) 
Pole (pol). The extremity of the axis of a sphere. 
Polyhydramnios (pol"i-hai-dram'ni-os). Hydramnion ; excess in the 

amount of the amniotic fluid. 
Posterior (pos-ti'ri-or). Situated dorsally or to the rear. 
Postnatal (post-ne'tal). Occurring after birth. 
Post-partum (post-par'tum). After or subsequent to child-birth. 

P. Chill, a chill, lasting several minutes, often following expul- 
sion of the child. 
P. Hemorrhage, hemorrhage following delivery. 
P. Shock, the exhaustion immediately following labor. 
Postpuerperal (post-piu-£r'p£-ral) . Occurring after child-birth. 
Pregnancy (pr^g'nan-si). [Latin, prag'nans, literally "previous to 
bringing forth."] The state of being with young or with child. The 
normal duration of pregnancy in the human female is two hundred 
and eighty days, or ten lunar months, or nine calendar months. 
Pregnant (pr^g'nant). With young or with child. 
Premature (pri-me-tiur'). Before it is ripe. 

P. Infant, an infant born after the period of viability but before 

the last two weeks of normal pregnancy. (Fig. 154.) 
P. Labor, labor which takes place during the last three months 

of the natural term, but before its completion. 
P. Respiration, respiration on the part of a child before it is 
completely born. 



GLOSSARY. 375 

Premonitory (pri-mon'i-to-n). Advising beforehand ; giving previous 
warning ; precursory ; applied to symptoms which give an indication 
or warning of the advent or onset of certain diseases, — for instance, 
chills, during the invasion of fever. 

P. Pains, painless uterine contractions before the beginning of 
true labor. 
Prepuce (pri'pius). The fold of skin which covers the glans penis in 
the male. 

P. of the Clitoris, the fold of mucous membrane which covers 
the glans clitoridis. 
Primigravida (prai-rm'-gnzv'i-da.). PI. primigravidce. A woman who 

is pregnant for the first time. 
Primipara (prai-rm'p'a-ra). PI. primiparce. A woman who has brought 

forth her first child. 

Prognosis (prog-no sis) . The foreknowledge of the course of a disease 

drawn from a consideration of its signs and symptoms ; the art of 

forecasting the progress and termination of any given case of disease. 

Prognostic Symptom (prog-nos'tt'c). A symptom from a consideration 

of which a prognosis of any particular disease is formed. 
Prognosticate (prog-nos'tt-cet). To make a prognosis. 
Prolapse (pro-laps')- A falling down, partial or complete, of some 
viscus, in its latest stage accompanied by protrusion so as to be partly 
external or uncovered. 

P. of the Cord, descent of the umbilical cord on the bursting of 

the bag of waters. (Fig. 106.) 
P. of the Uterus, descent of the uterus, " falling of the womb." 
Promontory (prom'on-to-n). A small projection;' a prominence. 

P. of the Sacrum, the superior or projecting portion of the 
sacrum when in situ in the pelvis, at the junction of the 
sacrum and the last lumbar vertebra. 
Prophylactic (prof-i-lac'tic). Belonging to prophylaxis ; preventive. 
Prophylaxis (prof-i-\ac'sis). The art of guarding against disease; the 
observation of the rules necessary to the preservation of health or 
the prevention of disease. 
Proteid (pro'ti-/d). Any one of a class of organic compounds forming 
the important part of animal and vegetable tissue. The proteid in 
milk is the part that forms the curd. 
Pruritus (pru-rai'tus). An intense degree of itching. 
Psychic, Psychical (sai'dc, sai'd-cal). Belonging to the mind or 

intellect. 
Ptyalism (tai'a-h'zm). Increased and involuntary flow of saliva. 
Puberty (pm'bev-ti). The age at which the generative organs become 

functionally active. 
Pubic (piu'bzc). Belonging to the pubis. 



$y6 GLOSSARY. 

Pubis (piu'bi's). The os pubis or pubic bone forming the front of the 

pelvis. (Fig. i.) sometimes, but incorrectly, written pubes. 
Pudenda (piu-d<?n'daj. Plural of pudendum. 
Pudendal (piu-d<?n'dal). Relating to the pudendum. 
Pudendum (piu-d^n'dum). [Latin, pude're, to have shame or modesty.] 
The external genital organs or parts of generation of either sex, but 
especially of the female : also used, perhaps more correctly, in the 
plural (pudenda). (See Fig. 8.) 
Puerpera (piu-£r'p£-raj. A woman in child-bed, or one who has lately 

been delivered. 
Puerperal (piu-£r'p£-ral). Belonging to, or consequent on, child- 
bearing. 

P. Convulsions, epileptiform convulsions occurring immediately 

before or after child-birth. 

P. Eclampsia, same as puerperal convulsions. See Eclampsia. 

P. Fever, a severe febrile disease which sometimes occurs in the 

puerperal state, usually about the third day after child-birth, 

accompanied by an inflamed condition of the peritoneum, 

due to septic infection. 

P. Insanity or Mania, insanity occurring in females towards 

the end of pregnancy or soon after delivery. 
P. State, the condition of a woman in, and immediately after, 
child-birth. 
Puerperium (piu-er-pi'ri-um). The state or period of a woman in 

confinement. 
Pulmonary (pul'mo-ne-n). Of the lungs or belonging to the lungs. 
Pulsation (pul-se'shon). Any throbbing sensation resembling the beat- 
ing of the pulse ; the heart's action extending to the arteries, felt in 
any part of the body. 
Purpura (pur'piu-raj. A disease in which there are small distinct 
purple specks and patches on the surface of the body, with general 
debility but not always fever. 
Purpuric (pur-piu'nc). Relating to purpura. 

Purulent (piu'ru-lrat). Consisting of pus; of the nature of pus. 
Pus (pus). A bland, cream-like fluid found in abscesses or on the 
surface of sores; matter; "corruption." 

Rational (rash'on-al). Conformable to reason or to a well-reasoned 
plan ; reasonable. Also applied to the mental state of a person. 

R. Symptoms, symptoms communicated by the patient to the 
physician; subjective symptoms. 
Reaction (ri-ac'shon). i. Increase of the vital functions succeeding 
their depression. 2. The phenomena resulting from the action of two 
or more substances upon each other. 



GLOSSARY. 377 

Rectal (rec'tal). Connected with or pertaining to the rectum. 

R. Alimentation, the administration of nourishment by means 
of enemata containing nutritive matter. 

Rectum (r^c'tum). The last portion of the large intestine, terminating 
at the anus ; the lower bowel. 

Reflex (ri'fiVcs). Reflected; caused by the conveyance of an impression 
to the central nervous system and its transmission through a motor 
nerve to the periphery. 

Regurgitation (ri-g^r-ji-te'shon). A flowing back; a flowing the wrong 
way: applied, for example, to the passive vomiting of infants and 
to the rising of food in the mouth of adults. 

Relaxation (ri-lac-se'shon). The reverse of contraction or tension; 
looseness; want of muscular tone or vigor. 

Remission (ri-mish'on). An abatement or diminution of symptoms. 

Renal (ri'nal). Belonging to the kidney. 

Respiration (res-pi-re'shon). The function of breathing, including both 
inspiration and expiration. 

Restitution (ris-tf-tiu'shdn). The act of restoring or returning some- 
thing, — particularly, rotation of the fetal head after its expulsion 
from the vagina, so that it looks in the same direction as it did 
before it entered the pelvic brim ; external rotation of the fetal head. 
(Fig. 44.) 

Resuscitation (ri-sus-t-te'shon). The act of restoring to life those who 
are apparently dead. 

Retained Placenta (ri-tend'). A placenta not expelled by the uterus 
after labor. 

Retention (ri-t^n'shon). The keeping back or stoppage of any of the 
secretions, particularly the urine. 

R. of Urine, a condition in which the urine is retained in the 
bladder and cannot be discharged voluntarily. 

Rhachitic (re-a't'ic). Relating to or affected with rhachitis or rickets. 
R. Pelvis, a pelvis deformed by rickets. 

Rhachitis (re-cai'tis). Rickets. 

Rickets (ric'ets). A disease of childhood in which there is a lack of 
the earthy salts in the bones, with resultant curvatures and deformi- 
ties of them, affections of the liver and spleen, and a condition of 
general weakness. Nourishing food, fresh air, exercise, and tonics 
furnish the best mode of treatment. 

Rotation (ro-te'shon). The act of turning round; the motion of any 
solid body about an axis. 

R. Stage of Labor, that stage of labor at which the presenting 
portion of the fcetus rotates or turns round. 

Rupture (rup'tshur). 1. Bursting or breaking of a part. 2. Hernia. 



378 GLOSSARY. 

Sacrum (se'crum). The triangular bone wedged between the ossa in- 
nominata, forming the posterior wall of the pelvis, articulating above 
with the vertebral column and below with the coccyx, and formed 
by the fusion of the five sacral vertebrae or segments. (Fig. I.) 

Sagittal (saj'i-tal). Relating to, or shaped like, an arrow. 

S. Suture, the suture which unites the parietal bones. (Fig. 27.) 

Saliva (se-lai'vaj. The colorless ropy fluid in the mouth secreted by 
certain glands and glandular structures in the mouth ; the spittle. 

Salivation (sal-i-ve'shon). An excessive flow of the saliva. The word 
is practically synonymous with ptyalism, but, strictly speaking, de- 
scribes the condition when produced by the exhibition of medicines. 

Saturated Solution (satsh'iu-re-t<?d). A solution which at a given 
temperature cannot contain more of the substance than it already 
contains. 

Scalpel (scal'pd). A small knife usually with a straight blade fixed 
firmly in the handle ; used in dissection and in surgical operations. 
(Fig. 92.) 

Scapula (scap'iu-laj. The shoulder-blade. 

Scrotum '(scro'tum). [Latin, "bag."] A pouch at the base of the penis 
in the male, containing the testicles and other organs. 

Sebaceous (si-be'shius). Fatty; suety ; applied to glands which secrete 
an oily matter resembling suet. Resembling or pertaining to sebum 
or fat. 

Sebum (si'bum). A thick, semi-liquid substance discharged upon the 
surface of the skin, composed of fat and broken-down epithelial cells. 

Secretion (si-cri'shon). 1. A function of the body by which various 
fluids or substances are separated from the blood, differing in differ- 
ent organs according to their peculiar functions : thus, the liver 
secretes the bile, the salivary glands the saliva, etc. 2. The substance 
secreted. 

Secundines (s<?c'un-dms). The after-birth; the placenta, etc., expelled 
after the birth of a child. (See Fig. 67.) 

Segmentation (seg-m<?n-te'sh<9n). The process of division by which the 
fertilized ovum multiplies before differentiation into layers occurs. 
(Fig. 18.) 

Semen (si'm^n). 1. A seed. 2. The fluid secreted by the male repro- 
ductive organs. 

Septic (s<?p'tic). Tending to putrefy; causing or due to putrefaction. 

Sepsis (sep'sis). 1. Putrefaction. 2. Infection and poisoning by putre- 
factive matter. 

Serous (si'rus). Of the nature of serum; secreting serum. 
S. Membrane. See under Membrane. 

Serum (si'rum). The clear, straw-colored liquid which separates, in the 
clotting of blood, from the clot and the corpuscles. 



GLOSSARY. 379 

Shock (shoe). A condition of sudden depression of the whole of the 
functions of the body, due to powerful impressions upon the system 
by physical injury or mental emotion. The former is termed surgical 
and the latter mental shock. 
Show (sho). i. Popularly, the red-colored mucus discharged from the 
vagina shortly before child-birth ; called also " Labor-show." 2. 
The vaginal discharge in menstruation. 
Sims's Position (sim'ztz). [J. Marion Sims, noted American gynaecolo- 
gist, deceased.] That position of the patient in which she lies upon 
the left side and front of the left chest, with the right leg strongly 
flexed, or "drawn up:" called also Semiprone position and Side 
position. (Fig. 102.) 

S.'s Speculum, a vaginal speculum with duck-bill blades : by it 

the posterior wall of the vagina is held up, while the anterior 

is depressed, the patient being placed in Sims's position. 

(Fig. 129.) 

Skim Milk (scim). Milk from which the cream has been removed, 

leaving only one or two per cent, of fatty matter. 
Smegma (smeg'mq.). [From a Greek word meaning soap.] Sebum, 
especially the offensive, soap-like substance produced from the seba- 
ceous follicles around the glans penis and prepuce and in the region 
of the clitoris and labia minora. 

S. Embryo'num. Same as Vernix Caseosa. 

Solution (so-liu'shon). 1. The act of dissolving a solid body. 2. A 

clear, homogeneous liquid having particles of a solid, another liquid, 

or a gas uniformly diffused through it, so that the particles are 

invisible and do not separate upon standing. 

Sordes (sor'diz). Literally, "filth:" applied to the foul matter which 

collects on the teeth, particularly in certain low fevers. 
Sound (saund). [French, sonder, to fathom, to try the depth of the sea; 
hence, to try or examine.] An instrument for introduction through 
the urethra into the bladder, or into any canal. (See Fig. 133.) 
Specific (spi-sif'zc). 1. Relating to a species; distinguishing one species 
from another. 2. Suited for a particular purpose : as, a specific 
remedy. 3. Produced by a special cause. 4. A specific remedy ; a 
remedy supposed to have a peculiar efficiency in the cure of a par- 
ticular disease, or one which has a special action on some particular 
organ. 

S. Disease, any disease produced by a special cause ; as syphilis 
and the eruptive fevers. (The term is frequently, but 
wrongly, restricted to syphilis.) 
S. Gravity, the weight of a body compared with that of another 
of equal volume taken as a standard : hydrogen is the 
standard for gases, and distilled water for liquids and solids. 



380 GLOSSARY. 

Spermatozoon (sp£r"ma-to-z6'on). PI. spermatozoa. The motile micro- 
scopic sexual element of the male, resembling in shape an elongated 
tadpole. (Fig. 17.) The male element in fecundation. 

Sterile (ster'il). 1. Affected with sterility; barren. 2. Not containing 
micro-organisms ; aseptic. 

Sterility (ste-riYl-ti) . Inability, whether natural or as the result of 
disease, to procreate offspring. 

Sterilization (st<?r"il-*'-ze'sh<m). The process of rendering an object 
sterile or free from micro-organisms or their germs. 

Sterilizer (st<?r'il-ai-z£r). An apparatus for sterilizing objects. (Fig. 

I73-) 

Stillborn (sUTborn). Born without life; born dead. 

Stimulant (sUm'iu-lant). 1. Stimulating. 2. A medicine having power 
to excite organic action or to increase the vital activity of an organ. 
A stimulant differs from a tonic in that its action is more speedy, 
more transitory, and usually followed by a reaction. 

Stimulate (sti'm'iu-let). To excite the organic action of a part of the 
animal economy. 

Stimulus (stim'iu-lus). PI. stimuli. A Latin word signifying a 
" goad," " sting," or " whip." In physiology, that which rouses or 
excites the vital energies, whether of the whole system or of a part. 

Stool (stul). The faeces discharged from the bowels; a dejection; an 
evacuation. 

Streptococcus (str<?p-to-coc'us). A variety of micro-organism. 

Stria (strai'aj. PI. stria. A Latin word signifying a "groove," "fur- 
row," or " crease." 

S. Gravidarum, shining, whitish lines upon the abdomen caused 
by pregnancy or distention by abdominal tumors. (Fig. 30.) 

Stupor (stiu'por). A suspension or diminished activity of the mental 
faculties ; loss of sensibility. 

Styptic (stip'tic). Having the power of stopping bleeding through an 
astringent quality ; haemostatic. 

Subcutaneous (sub-ciu-te'ni-us). Situated just under the skin. 
S. Injection. See Hypodermic Injection. 

Suppository (su-poz'i-to-ri) . A preparation of some substance (usually 
cacao butter) fusible at the temperature of the body, and combined 
with some medicinal substance, for introduction into the rectum, 
vagina, urethra, or other cavity of the body. 

Suppuration (sup-iu-re'shon). The formation of pus or the processes 
giving rise to it. 

Suppurative (sup'iu-re-tiv). Producing or discharging pus. 

Suture (siu'tshur). 1. The junction of the bones of the cranium by a 
serrated line resembling the stitches of a seam. (Fig. 27.) 2. A 
stitch used to draw together the lips of a wound. 3. The thread or 
material used in making a stitch. 



GLOSSARY. 381 

Syphilis (stf'*-h's). A contagious venereal disease, communicable by 
contact of any abraded surface with the virus in coition or otherwise, 
and also by heredity and from the mother to a foetus. 

Symphyseotomy (smr"fx'z-i-ot'o-mO. The operation of severing the 
ligaments and the fibro-cartilages of the pubic symphysis; done in 
difficult labor. 

Symphysis (sim'fi-sts). The union of bones by means of an intervening 
substance ; a variety of synarthrosis. 

S. Pubis, " symphysis of the pubis," the pubic articulation or 
union of the pubic bones which are connected with each 
other by interarticular cartilage. (Fig. 1.) 

Synchondrosis (sm-con-dro'sis). A union of bones by intervening car- 
tilage; a variety of synarthrosis. See Articulation. 

Syncope (sm'co-pi). Literally a "cutting short" of one's strength; 
swooning or fainting; a suspension of respiration and the heart's 
action, complete or partial. 

T-Bandage. A bandage shaped like the letter T, — especially one in 
which the transverse limb passes around the body and the longitu- 
dinal one under the perineum. Used to hold dressings against the 
vulva. 

Tampon (tam'pon). 1. A portion of gauze, sponge, etc., used in plugging 
a cavity or canal. 2. To apply a tampon to. 

Tamponade (tam-po-ned')- The use of the tampon or the act of using it. 

Tamponage (tam'pon-ej). See Tamponade. 

Tamponing (tam'pon-mg). The act of using a tampon. 

Tenaculum (ti-nac'iu-lum). A small hook-shaped instrument. 
T. Forceps, a volsella. 

Tenesmus (tt-n^z'mus). A constant desire to go to stool or to urinate, 
with painful straining without the expulsion of faeces or urine. 

Testicle (tes'ti-c\). One of the two glands in the male contained in the 
scrotum. 

Thoracic (tho-nzs'ic). Belonging to the thorax. 

Thorax (tho'racs). The chest, or that part of the body between the 
neck and the diaphragm and in the cavity of which are contained 
the heart and lungs. 

Thrombosis (throm-bo'sis). The formation or progress of a thrombus. 

Thrombotic (throm-bot'ic). Relating to or of the nature of thrombosis. 

Thrombus (throm'bus). A clot formed in any part of the circulatory 
apparatus. It differs from an embolus in that it is developed at the 
point where it is found, while an embolus is brought from a distance 
through the blood-vessels. 

Tissue (Ush'u). A web-like structure; a collection of cells or elements, 
of a constant structure and function, which go to make up the body. 
Examples : muscular tissue ; brain tissue ; bone tissue, etc. 



382 GLOSSARY. 

Torsion (tor'shon). A twisting. 

T. of the Umbilical Cord, the normal spontaneous twisting of 
the umbilical cord. 

Toxemia (toc-si'mi-aj. Blood-poisoning. 

Toxemic (toc-si'mic). Relating to, or caused by, toxaemia. 

Traction (trac'shon). The act of drawing or pulling. 

Trendelenburg's Position or Posture (tr^n'd^-kn-burgz). That posi- 
tion in which the patient is placed flat on the back with body and 
thighs elevated to an angle of about forty-five degrees, the legs 
hanging over the edge of the table. It is used in abdominal surgery 
so that the abdominal viscera may be kept out of the way by gravi- 
tation. (Fig. 108.) 

Tubercle (tiu'b^r-cl). A rounded eminence. 

Tuberculosis (tiu-ber-ciu-16'sis). A specific infectious disease due to 
the presence of the tubercle bacillus and affecting most often the 
respiratory and alimentary tracts, the peritoneum and parts of the 
brain. When the disease affects the lungs it is popularly known as 
" consumption." 

Tumor (tiu'mor). 1. A swelling. 2. A morbid growth of new tissue in 
any part of the body, not due to inflammation, and differing in 
structure from the part in which it grows. Tumors may be solid 
or hollow (Cystic t.). When a tumor tends to recur after removal, 
and infect the system, it is called Malignant; when it does not, 
Benign, Innocent, or Non-malignant. 

Tympanites (tim-pa-nai'tiz). Distention of the abdomen by gas in the 
intestines or in the peritoneal cavity ; drum belly. 

Uterine T., distention of the uterus with gas; physometra. 

Typhoid State (tai'foid). A condition sometimes occurring in de- 
pressing diseases, in which there are great muscular weakness, brown 
tongue, muttering delirium, feeble pulse, and involuntary passage of 
urine and faeces. 

Ulcer (ul'ser). A loss of substance on some internal or external surface 

from gradual disintegration and destruction of the tissue. 
Ulcerate (ul's^-ret). 1. To form an ulcer in. 2. To become affected 

with ulcers. 
Umbilical (um-bzTz-cal). Pertaining to the umbilicus. 

U. Arteries, the arteries which accompany and form part of the 

umbilical cord. 
U. Cord [Latin, funis umbilicalis], the cord connecting the pla- 
centa with the umbilicus of the child, and at the close of 
gestation principally made up of the two umbilical arteries 
and the umbilical vein, encased in a mass of gelatinous tissue 
called " Wharton's jelly." 
U. Hernia, hernia at or near the umbilicus. 



GLOSSARY. 383 

Umbilicus (um-bz-lai'cus). The navel; the pit in the centre of the 

abdomen left by the shrinking of the umbilical cord. 
Uremia (iu-ri'mi-3). The presence of urinary constituents in the blood, 
due to the suppression of the urine, and marked by headache, nausea, 
vertigo, eclampsia, and a peculiar odor of the skin. 
Uremic (iu-ri'rm'c). Relating to uraemia; affected with uraemia. 
Urea (iu'ri-aj. The principal solid constituent of the urine. It is pro- 
duced by the decomposition of proteids and carries off most of the 
nitrogenous products of the body. Urea is also found in the blood 
and lymph. 
Urethra (iu-ri'thra.). The membranous canal forming a communication 
between the neck of the bladder and the external surface of the 
body. The female urethra does not exceed two inches in length, and 
the passage is considerably larger and more dilatable than that of 
the male. 
Urethral (iu-ri'thral). Belonging to the urethra. 
Urinal (iu'n'-nal). A vessel to receive urine. 
Urinalysis (iu-ri-naYi-sis). Chemical analysis of the urine. 
Urinary (iu'n'-ne-n). Relating to the urine. 
Urinate (iu'n-net). To pass urine from the bladder. 
Urination (iu-n-ne'shon). The act of passing urine. 
Urine (iu'rm). The saline secretion of the kidneys which flows from 
them through the ureters into the urinary bladder. 

Incontinence of U., inability to retain the urine in the bladder, 
so that it escapes without the knowledge or control of the 
patient. 
Retention of U., inability to pass the urine which accumulates 

in the bladder. 
Suppression of U., arrested secretion of urine from the kidneys. 
Urinometer, Urometer (m-ri-nom' e-ter) . An hydrometer for ascertain- 
ing the specific gravity of urine. 
Uterine (iu'te-rm). Relating to the uterus. 

U. Appendages, the ovaries and Fallopian tubes. (Fig. 11.) 
U. Colic, paroxysms of pain in the uterus due to menstruation 

or to other causes, such as " false pains" or " after-pains." 
U. Gestation, normal pregnancy. 

U. Inertia, deficiency of contractile power of the uterus in labor. 
U. Involution, the process by which, after child-birth, the uterus 

reassumes its normal size and shape. 
U. Mole, a mass sometimes occurring in the uterus, consisting 

of a dead foetus which has undergone degeneration. 
U. Phlebitis, a form of puerperal fever. 

U. Pregnancy, normal pregnancy occurring in the uterus, as 
opposed to ectopic pregnancy. 



384 GLOSSARY. 

U. Probe, a long, flexible probe for exploring the cavity of the 

uterus. (See Fig. 133.) 
U. Sinuses, cavities formed by the uterine veins in the walls 
of the uterus ; they are especially conspicuous in the preg- 
nant uterus. 
U. Sound, an instrument somewhat resembling a urethral sound, 
used in making examinations of the uterus ; a uterine probe. 
(Fig. 133.) 
U. Tubes, the Fallopian tubes. (Fig. 11.) 

U. Wound, the area of the uterus from which the placenta has 
been detached. 
Uterus (iu't^-rus). The womb, a hollow muscular organ designed for 
the lodgement and nourishment of the foetus during its development 
until birth. (Figs. 9, 10, and 11.) 

Vagina (ve-jai'naj. [Latin, a sheath.] The curved canal, five or six 
inches in length, extending from the vulva to the uterus. (Fig. 9.) 
Vaginal (vaj'i-ndl). Belonging or relating to the vagina. 

V. Examination, examination of the vagina by introducing a 

finger. (Fig. 56.) 
V. Speculum, an instrument for keeping open the vagina in 
order that its interior may be viewed. (Figs. 129 and 130.) 
Varicose (var'i-cos). Unnaturally dilated; relating to a varix. 
Varicosity (var-i-cos'i-ti). 1. A varicose condition of the veins; vari- 

cosis. 2. A varicose vein ; a varix. 
Varix (ve'n'cs). A dilatation of a vein. (Fig. ^S-) 
Vascular (vas'ciu-laj). Having, or relating to, vessels; full of blood- 
vessels. 
Vascularity (vas-ciu-lar'i-ti)- The state or property of being vascular. 
Vectis (vec'tis). The lever. In obstetrics, an instrument resembling 
one blade of an obstetrical forceps, for making traction upon the 
head of the foetus in retarded labor. -Seldom used and never seen 
now, as a single forceps blade answers the same purpose. 
Vein (ven). A tube conveying blood from the various tissues of th° 

body to the heart. 
Venous (vi'nus). Relating to the veins; contained in the veins. 

V. Blood, a dark-colored liquid collected in the veins from every 
part of the system. It is subsequently exposed to the in- 
fluence of the air in the lungs and is converted into bright 
red arterial blood. It contains more carbonic acid gas and 
less oxygen than arterial blood. 
V. Circulation, the circulation of the blood through the veins. 
V. Congestion, the engorgement of an organ with venous blood 
caused by interference with its return to the heart. 



GLOSSARY. 385 

Vernix Caseosa. " Cheesy Varnish." The layer of fatty matter which 
covers the skin of the foetus. 

Version (ver'shon). The act of turning; specifically, a turning of the 
child in the uterus so as to change the presenting part and bring it 
into more favorable position for delivery. (Figs. 71 and 72.) 

Vertebra (wr'ti-braj. PI. vertebra. A peculiarly shaped bone, thirty- 
two of which compose the spine or vertebral column. 

Vertex (ver'tecs). The summit or top of anything. In anatomy, the top 
or crown of the head. 

V. Presentation, presentation of the vertex of the foetus in 
labor. (Fig. 41.) 

Vertigo (ver'ti-go). Dizziness; swimming of the head ; giddiness. 

Vesical (xes'i-ca\). Pertaining to the bladder; having the appearance 
of a bladder. 

Viability (xai-a-bil'i-ti). Ability to live. 

Viable (vai'a-bl). A term in medical jurisprudence signifying "able or 
likely to live :" applied to the condition of the child at birth. 

Virgin (wr'jm). A woman who has never had sexual intercourse. 

Virulent (vir'iu-lent). Poisonous; malignant; caused by virus or 
having the nature of virus. 

Virus (vai'rus). Any poisonous matter produced by disease and capable 
of propagating that disease by inoculation ; a deleterious agent sup- 
posed to be a parasitic organism or germ. 

Viscus (vis'cus). PI. viscera. Any organ contained in the cavities of 
the body, especially within the abdomen. 

Visual (vzzh'iu-al). Pertaining to, or used in, vision or sight. 

Vital (vai'tal). Belonging or essential to life. 

Vitality (vai-tal't-U)- The principle of life. 

Volsella (vol-sd'g.). A forceps each blade of which has hooked ex- 
tremities ; a volsellum. 

Vulsella, Vulsellum (vul-sd'3, vul-sd'um). See Volsella. 

Vulva (vul'vaj. The external genitals of the female. (Fig. 8.) 

Walcher Position or Posture (val'ccr or wal'tsh^r). That position 
of the patient in which she lies on her back with her buttocks 
raised and well over the edge of the table and her limbs hang- 
ing down as much as possible. (See Fig. 75.) In this position the 
true conjugate diameter of the pelvis is lengthened by nearly half 
an inch. 

Wet-Nurse. One who gives suck to the child of another. 

Wharton's Gelatin or Jelly (hwor'tonz). [Thomas Wharton, English 
anatomist, died 1673.] The jelly-like mucous tissue composing the 
bulk of the umbilical cord. 

Whites (hwaits). A popular name for Leucorrhcea, which see. 

25 



386 GLOSSARY. 

Winckel's Disease (vmc'elz). A very rare and extremely fatal disease 
of new-born infants, marked by icterus, hemorrhage, bloody urine, 
and cyanosis. Malignant jaundice. 

Witches' Milk (witsh'ez). A milky fluid secreted from the breast of 
the newly born. 

Womb (wum). The Uterus, which see. 



INDEX 



¥¥ 



Abdomen, pigmentation of, 68, 102 

size of, 102, 103 
Abdominal binder. See Binder, 123, 

234 

changes, 102 

flattening, 102 

pregnancy, 93 

supporter, 235 
Abortion, 261 

after treatment, 269 

most common cause of, 97 
Accidental hemorrhage, 202 
Accidents and emergencies, 201 
Active fetal movements, 103 
After-birth, expulsion of, 165 
After-coming head, delivery of, 173 
After-pains, 226 
Air embolism, 221 
"Air hunger," 91 
Albuminuria, symptoms of, 83 
Amnion, 46, 47 
Amniotic sac, 46 

formation of, 46 
functions of, 47 
layers of, 47 
Amount of food for premature 

infant, 297 
Anaemia, 79 

of pregnancy, 79 

onset of, 79 

symptoms of, 79 

treatment of, 79 
Analysis of milk, 320 

of urine in pregnancy, 116 
Ankylosis, pelvic, 25 
Anointing the infant after birth, 
271 



Appetite after labor, 227 

in pregnancy, 67 

in puerperium, 227 
Areola of the breast, 36 
Arm presentation, 138 
Arnold sterilizer, ^^7 
Arteries, hypogastric, 59 

umbilical, 56 
Articulation, sacro-coccygeal, 24 
Articulations of pelvis, 24 
Artificial feeding, 325 

of premature infant, 298 

respiration, 211 
Ascites, 80 

treatment of, 80 
Asphyxia neonatorum, 210 
causes of, 210 
treatment of, 211 
varieties of, 211 
Ass's milk, 326 
Axis-traction forceps, 182 

Baby clothes, 127, 280 

foods, 325 

" seven months," 139 
" Baby-food babies," 326 
Bacteria in nursery, 285 
Bad milk, effect on infant, 322 
Bag, Barnes's, 184 

Champetier de Ribes, 184 

of membranes, 47 
Ballottement, 103 
Barley-water, 334 
Barnes's bag, 184 
Basiotribe, 196 

Basket, for premature infant, 290 
Bassinette, 146 

387 



3 88 



INDEX. 



Bath, infant's, 274 

temperature of, no 

shower, no 
Bathing, no 

in pregnancy, no 

in puerperium, 245 

of premature infant, 294 

sea, no 

spray, no 

surf, in 
Bed, care of, 238 

preparation for labor, 147 
Bed-pads, 123 
Bedroom in pregnancy, in 
Bicycling, 109 
Binder, 234 

abdominal, 123, 234 

flannel, for baby, 126 

for breasts, 258 

function of, 234 
Bipolar version, 178 
Birth-marks, 341 
Birth of child, 165 

of head, 168 
Bladder, irritability of, 79, 99 
Bleeding, from infant's vagina, 307 

from navel, 2S6 
Blood, in milk, 323 

of pregnancy, 65 

poisoning, 262 
" Blue babies," 308 
Bottled milk, 327 
Bougie, 199 

Bowels in puerperium, 242 
Braun's hook, 197 
Braxton-Hicks version, 178 
Breast-binder, 256 

pattern of, 257 
Breast feeding, 311 

first meal, 312 

hours for nursing, 313 

indications for stopping, 

323 
milk, 310 



Breast milk, effect of fright, 323 
of menstruation, 323 
of nervous shock, 323 
of pain, 323 
of worry, 323 
insufficiency of, 318 

causes of, 319 
methods of increasing, 320 
quality of, 318 
quantity of, 319 
Breast-pump, 295 
care of, 297 
method of use of, 295 
Breasts, " caked," 320 
care of, 311, 314 
care in last weeks, 117 
changes due to pregnancy, 64 
diseases of, 252 
dragging of, 315 
eczema of, 258 
inflammation of, 254 
massage during pregnancy, 117 

in puerperium, 253 
method of " drying up," 339 
pigmentation of, 65, 101 
striae of, 64, 117 
Breech case, diagnosis of, 173 
diagnosis of, 138 
management of, 172 
presentation, 134 
Brim of pelvis, 23 
Brow presentation, 134 
Bulb and valve syringe, 187 
Buttocks, chafing of, 282 
" scalding" of, 282 

Csesarean section, 27, 186 

assistants needed, 188 
dangers of, 18b 
in private practice, 190 
indications for, 187 
nurses needed, 188 
preparation of patient, 188 

" Caked" breasts, 320 



INDEX. 



389 



Calisthenics, 109 

Caput succedaneum, 300 

Care of breast-pump, 297 

of breasts, 311 

of instruments, 233 

of nipples, 311 

of normal infant, 271 

of nursing bottles, 334 
Cascara sagrada, dose of, ~$ 
Castor oil in pregnancy, 75 
Catheter, best kind, 240 

method of use, 240 

sterilization of, 240 

withdrawal of, 242 
Catheterization, difficulties after 
labor, 240 

in puerperium, 239 
Cause of labor, 138 
Cavity of the uterus, 2> 2 
Centrifugal cream, 328 
Cephalhematoma, 302 
Certified milk, 327 
Cervical laceration, hemorrhage 

from, 214 
Cervix, dilatation of, 184 

immediate repair, 215 

uteri, 32 
Cessation of menstruation, 99 
Chafing of buttocks, 282 
Champetier de Ribes bag, 184 
" Change of life," 42 
Chapin dipper, 330 
Chemistry of milk, 320 
Child, asphyxia of, 210 

birth of, 165 
Child-bed fever, 248 
Chill following labor, 224 

in puerperium, 224 
Chloasmata, 68 
Chloroform, administration of, 159 

Esmarch inhaler, 160 

in labor, 158 
" Chloroform cough," 161 
Chorea, 72 



Chorion, 47 

Circulation, fetal, 58 

Clitoris, 28 

Clothing for infant, 127, 280 

for premature infant, 288 

in pregnancy, 105 
Coccyx, 23 
Colostrum, 65, 101 

corpuscles, 65 
Combined version, 178 
Concealed hemorrhage, 90, 95, 202 
Conception, 45 
Condensed milk, 326 
Conduct of labor, 151 

of third stage, 172 
" Cone" for administering ether, 

162 
Confinement, 139 
Congenital cyanosis, 308 
Constipation, after labor, 227 

in pregnancy, 74 

in puerperium, 227 

treatment of, 115 
Contraction of pelvis, 25 
Control of sex, 343 
Convulsion, eclamptic, 85 

treatment of, 88 

ursemic, 113 
Cooke Maternity Outfit, 127 

incubator, 279 
Cord about neck, 168 

dressing of, 271 

hemorrhage from, 299 

ligation of, 169 

prolapse of, 207 

secondary hemorrhage from, 
222 

separation of, 286 

umbilical, 47 
Corsets, 105 

Cotton jacket, for premature in- 
fant, 288 
when changed, 294 
Cough, 81 



390 



INDEX. 



Cough from chloroform, 161 

in pregnancy, 67 
Cow's milk, 327 

composition of, 328 
modification of, 328 
Cranioclast, 196 
Craniotomy, 183, 195 
Cream, centrifugal, 328 

gravity, 328 
Croquet, 109 
Crusts on scalp, 283 
Cry of premature infant, 293 
Crying baby, 284 
Curd of milk, 320 
Curettage, 263 

dressings needed, 268 

instruments used, 264 

light for, 268 

position of nurse, 269 

preparations for, 264 

table for, 267 
Cyanosis in new-born infant, 308 

Dance, St. Anthony's, 82 

St. John's, 82 

St. Vitus's, 82 
Dancing, no 

Danger of ophthalmia neonato- 
rum, 303 
Dangers of abortion, 262 

of Caesarean section, 186 

of embolism, 221 

of forceps, 182 

of miscarriage, 204, 262 

of placenta prsevia, 94 

of post-partum hemorrhage, 
221 

of version, 180 
Date of labor, 104 
Davidson syringe, 184 
Death of foetus, 204 
Decapitation, 196 
Decollete gowns, 117 

in pregnancy, 107 



Decidua, 45 

of pregnancy, 45 

reflexa, 46 

serotina, 45, 46 

vera, 45 
Deformity of pelvis, 26 
Delivery, 139 

by forceps, 180 

by the nurse, 166 

by version, 177 

of after-coming head, 173 

of breech, 173 

of placenta, 172 

of shoulders, 168 

of twins, 174 

operative, 177 

rapid, 200 
Development of foetus, 53 

of premature infant, 298 
Diagnosis of breech, 173 
Diaper for premature infant, 288 

method of applying, 280 
Diapers, 126 
Diarrhoea in pregnancy, 75 

treatment of, 116 
Diet after labor, 245 

in pregnancy, 112 

in puerperium, 245 
Diet-sheet for pregnant woman, 

114 
Digestive organs in pregnancy, 67 
Dilatation of cervix, 184 
Dipper, Chapin, 330 
Discipline of infant, 284, 285 
Diseases of the heart, 79 

of new-born infant, 302 
Disinfection of the hands, 167 
Dislocations at birth, 300 
■ Disorders of pregnancy, 71 

of puerperium 248 
Displacements of the uterus, 83 
Dose of cascara sagrada, 75 
Douche, vaginal, 243 

amount of, 244 



INDEX. 



391 



Douche, temperature of, 244 
" Dragging" of the breasts, 315 
Dressing the cord, 272 
Drinking-water for infant, 286 
Driving, 109 
Dropsy, 80 

treatment of, 80 
Drugs excreted by milk, 339 
" Dry up" breasts, 339 
Ductus arteriosus, 60 

venosus, 60 
Duration of labor, 143 
Dyspnoea in pregnancy, 67, 76 

Eclampsia, 84, 201 
cause of, 84, 113 
character of convulsions, 85 
diagnosis of, 85 
in puerperium, 213 
symptoms of, 84 
treatment of, 87 
treatment of convulsions, 87 
Ectopic gestation, 91 
causes, 91 

hemorrhage in, 203 
management by nurse, 203 
symptoms, 92 

of rupture of sac in, 
203 
time of rupture, 203 
treatment, 93 
varieties, 92 
Eczema of breast, 258 
" Eight per cent, milk," 331 
Elliott forceps, 182 
Embolism, 221 
air, 221 

dangers of, 221 
symptoms of, 221 
treatment of, 221 
Embryo, 50 

at four weeks, 51 
Embryotomy, 194 
indications, 194 



Emergencies, 201 
English breast-pump, 295 
Epilepsy, 87 
Episiotomy, 193 
Eruptive fevers, 96 
Esmarch apparatus for administer- 
ing chloroform, 160 
Ether, administration of, 163 

in labor, 162 

" cone," 162 
Evisceration, 197 
Examination of milk, 321 

of urine, 69 

vaginal, 156 
Excretive organs in pregnancy, 67 
Exercise, 107 

amount in pregnancy, 108 

bicycling, 109 

calisthenics, 109 

croquet, 109 

driving, 109 

games, 109 

golf, 109 

horseback riding, 109 

out-door, 109 

ping-pong, no 

tennis, 109 

walking, 109 
Expulsive forces of labor, 129 
Extension, 132 
External hemorrhage, 202 

organs of generation, 28 

os, 28 

pelvimetry, 26 

rotation, 132 

version, 178 
Extra-uterine pregnancy, 92 

Face presentation, 133 
Fainting, 81 

in pregnancy, 201 
Fallopian tubes, 31, 43 
False labor-pains, 152 
Fat in milk, 320 



392 



INDEX. 



Feeble infants, 287 

" Feeder" for premature infants, 

296 
Feeding, artificial, 325 

mixed, 325 
" Ferris waist," 105 
Fetal circulation, 57 

development, 43, 51 

heart, 104 

skull, 54 
Fever, child-bed, 248 

" milk," 227 

puerperal, 248 

scarlet, 96 
Fevers, eruptive, 96 
" Figure-of-eight" ligature, 222 
First stage, conduct of, 154 
Fissure of nipple, 252 
Flannel binder for baby, 126 
Flattening of abdomen, 102 
Flexion, 132 

Flowers in lying-in room, 246 
Foetus, 50 

at four weeks, 51 

at three months, 51 

at six months, 50 

at seven months, 53 

at eight months, 53 

at nine months, 53 

at term, 53 

circulation of, 58 

death in utero, 204 

development in multiple preg- 
nancy, 61 

development of, 51, 53 

head of, 53 

nourishment of, 56 

overgrowth of, 112 

position in utero, 53 

skull of, 51 
Follicle, Graafian, 2>1 
Fontanelles, 55 

Food for premature infant, 295 
Foot presentation, 138 



Foramen ovale, 59 
Forceps, axis-traction, 182 

dangers of, 182 

delivery by, 180 

Elliott, 182 

high, 180 

indications for, 184 

low, 180 

medium, 180 

paralysis from, 300 

position of patient, 182 

preparations for, 181 

pressure from, 300 

Simpson, 182 

sterilization of, 184 

Tucker-McLane, 182 

types of, 182 
Formaldehyde fumigator, Lister's, 

145 
Fornix, 26 

" Four per cent, milk," 328 
Fractures at birth, 300 
Freeman pasteurizer, 338 
Fright, effect on breast milk, 323 
Fumigation, 145 

Fundus, management after labor, 
228 
in third stage, 169 

relaxation of, 229 

uteri, 32 
Funis, 48 
Furniture of lying-in room, 145 

of nursery, 285 

Gait in pregnancy, 69 

Galbiati knife, 192 

Games, 109, no 

Garters, 107 

Generation, external organs of, 28 

internal organs of, 29 
" Gertrude" garments for infants, 

127 
Gestation, ectopic, 93 

multiple, 61 



INDEX. 



393 



Glands, mammary, 35 

of Montgomery, 65 
Goat's milk, 326 
Golf, 109 

Gowns, decollete, 107, 117 
Graafian follicle, 37, 43 
Granny knot, 171 
Gravity cream, 328 
Guaranteed milk, 327 

Hair, growth during pregnancy, 

67 
Hands, disinfection of, 167 
Head, birth of, 168 

delivery in breech case, 173 

injuries at birth, 300 
Headache, 81 
Heart clot, 221 

diseases of, 79 

failure in labor, 207 

palpitation of, 56, 71 
Heart-sounds, fetal, 104 
Hemorrhage, 90 

accidental, 202 

concealed, 91, 95, 202 

during pregnancy, 201 

external, 202 

internal, 96 

from cervical laceration, 214 

from cord, 222, 299 

from navel, 222 

general treatment of, 90 

post-partum, 215 

symptoms of, 91 

unavoidable, 202 

varieties of, 90, 91 
Hemorrhoids, 78 

treatment of, 78 
Hernia, umbilical, 307 
High forceps, 180 
Horseback riding, 109 
Hours for nursing, 313 
Hypogastric arteries, 59 
Hysterin, 87 



Icterus neonatorum, 292, 304 
Ilium, 22 

crest of, 23 
Impacted shoulder presentation, 197 
Impregnation of ovum, 43 

usual site of, 43 
Impressions, maternal, 341 
Inclined planes of pelvis, 131 
Incubator, 291 

principle of, 291 

temperature of, 293 

ventilation of, 292 
Indications for Caesarean section, 

187 

for embryotomy, 194 

for forceps, 184 

for version, 184 
In-door exercise, 109 
Induction of labor, Krause method, 
199 

of premature labor, 199 
Infant, anomting, 271 

at term, length of, 53 
weight of, 53 

bleeding from vagina, 307 

care of, 271 

clothing, 127, 280 

congenital cyanosis, 308 

crying, 284 

discipline of, 284, 285 

diseases of, 302 

dislocations at birth, 300 

drinking-water for, 286 

effect of bad milk, 322 

feeble, 287 

feeding, 310 

care of breasts and nippies, 

methods of, 310 
mother's milk, 311 
sugar solution, 312 
wet-nurse, 324 

first bath, 273 

first outings, 285 



394 



INDEX. 



Infant, fractures at birth, 300 
gain in weight, 317 
hernia at navel, 307 
inflammation of breast, 305 
initial loss of weight, 317 
injuries to, 300 
jaundice of, 304 
length of, 53 
" lockjaw," 308 
loss of weight, 317 
" marked," 341 
mastitis, 305 
night-gown, 283 
opisthotonos, 308 
outfit, 125 
playing with, 285 
premature, 287 
regurgitation, 317 
rocking to sleep, 284 
sleep, 284 
tetanus, 308 
trismus, 308 
umbilical hernia, 307 

vegetations, 308 
undeveloped (see premature), 

287 
vaginal discharge, 307 
visitors, 285 
vomiting, 317 

weight of, 53 
Infant's bath, management of, 278 

preparations for, 274 

temperature of, 276 
food, amount at each feeding, 

333 
preparation of, 331 

sleep, training, 284 
Inflammation of breast, 254 

in new-born infant, 305 
Infusion, saline, 220 
Injuries to infant, 300 

to infant's head, 300 
Inlet of pelvis, 24 
Insanity, 258 



Insanity during labor, 259 

of lactation, 259 

of pregnancy, 258 

of puerperium, 258 

puerperal, 258 

treatment of, 259 
Insomnia, 81 
Instruments, care of, 233 
Internal hemorrhage, 96 

organs of generation, 29 

os, 33 

pelvimetry, 27 

version, 180 
Interstitial pregnancy, 92 
Intertrigo, 282 
Introduction of catheter, 240 
Inversion of uterus, 206 
Involution of uterus, 117, 225 
Irritability of bladder, 79, 99 
Ischium, 23 
Itching, 82 

Jaundice of the new-born, 304 
Joints of pelvis, 24 

Kelly pad, 157 
Knee-chest position, 209 
Knot, Granny, 171 

square, 170 
Krause method of inducing labor, 
199 

Labia majora, 28 

minora, 29 
Labor, appetite after, 227 

cause of, 138 

chill following, 224 

chloroform in, 158 

conduct of, 152 

of first stage, 154 
of second stage, 158 
of third stage, 172 

constipation after, 227 

date of, 104 



INDEX. 



395 



Labor, diet after, 245 

duration of, 143 

ether in, 162 

expulsive forces of, 129 

induction of, 199 

heart failure in, 207 

insanity during, 259 

mechanism of, 129 

normal, 152 

phenomena of, 139 
of first stage, 141 
of second stage, 142 
of third stage, 143 

precipitate, 175 

premature, 261, 269 

premonitory symptoms of, 138 

preparations for, 144 

probable date of, 140 

pulse after, 224 

resistant forces of, 129 

stages of, 141 

symptoms of, 140 

temperature after, 225, 244 

unassisted, 152 

uterus after, 225 
Labor-pains, 141 

false, 152 

true, 153 
Lacing in pregnancy, 106 
Lactation, insanity in, 259 
Lactose, 320 
Lead poisoning, 97 
Leg-holder, Cooke's, 264 

Robb's, 264 
Length of normal infant, 53 
Leucorrhcea, 82 
Ligature, figure-of-eight, 222 
Ligation of cord, 169 
Light for premature infant, 294 
Linse albicantes, 64 
Liquor amnii, 46 
Lister's formaldehyde fumigator, 

145 

Lithotomy position, 263 



Lochia, 226 

amount of, 226 
character of, 226 
odor of, 226 
return of, 226 
suppression of, 226 
" Lockjaw," 308 
Locked twins, 174 
Low forceps, 180 
Lubrichondrin, 241 
Lungs in pregnancy, 65 
Lying-in, 139 

room, choice of, 144 

fumigation of, 145 
furniture of, 145 
preparation of, 145 
ventilation of, 246 
state, 224 

Malaria, 97 
Male element, 43 
Mammae, 35 
Mammary changes, 101 

glands, 35 
Management of breech cases, 172 

of pregnancy, 105 

of puerperium, 228 
Mania, puerperal, 258 
Massage of breasts, 253 

in pregnancy, 117 

of nipples, 117 
Mastitis, 255 

occurrence of, 255 

of infants, 305 

symptoms of, 256 

treatment of, 256 
Maternal impressions, 341 
Maternity charts, 122 

outfit, Cooke's, 127 
Meatus urinarius, 29 
Mechanism of- labor, 129 
Meconium in breech presentation, 

135 
Medium forceps, 180 



396 



INDEX. 



Melancholia, puerperal, 259 
Membranes, artificial rupture of, 
168 

bag of, 47 
Menopause, 42 

and pregnancy, 42 

symptoms of, 42 
Menstruation, 37, 39 

abnormal, 39 

amount of, 39 

cessation of, 99 

characteristics of, 39 

duration of, 39 

effect on breast milk, 323 

normal, 40 

phenomena of, 39 

regularity of, 39 

symptoms of, 39 

types of, 40 
Milk, ass's, 326 

blood in, 323 

bottled, 327 

certified, 315, 327 

chemistry of, 320 

condensed, 326 

curd of, 320 

drugs excreted by, 339 

" eight per cent.," 331 

examination of, 321 

fat in, 320 

" four per cent.," 328 

from herd, 327 

goat's, 326 

guaranteed, 327 

one cow's, 326 

pasteurization of, 338 

proteids in, 320 

pus in, 323 

sterilization of, 336 

sugar in, 320 

to " dry up," 339 

top, 329 

" twelve per cent.," 329 
" Milk fever," 227 



" Milk leg," 257 
Milk-sugar, 320 
Miscarriage, 261 

after treatment, 269 

causes of, 261 

dangers of, 204, 262 

prevention of, 192, 204 

symptoms of, 204, 261 

threatened, 204 

treatment of, 262 
Mixed feeding, 325 
Mons veneris, 28 
Montgomery, glands of, 65 

tubercles of, 65 
" Morning sickness," character of, 
100 
treatment of, 71 

vomiting, 99 
Mother's mark, 341 

milk, 311 

normal, 321 
Multiple gestation, 62 
Mutilating operations, 194 

Nausea of pregnancy, 71 
Navel, 48 

bleeding from, 286 

rupture at, 307 

secondary hemorrhage, 222 
Nervous disorders in pregnancy, 69, 
116 

shock, effect on milk, 323 
Neuralgia, 81 
Night-gown, infant's, 283 
Nipple shield, 254 
Nipples, care of, 311 

in pregnancy, 117 

depressed, 117 

diseases of, 117, 252 

erosions of, 117 

fissures of, 117, 252 

flat, 117 

massage of, 117 

size of, 334 



INDEX. 



397 



Nipples, small, 117 

syphilis of, 258 
Noise and premature infants, 294 
Normal infant, care of, 271 

labor, 152 

mother's milk, 321 
Nurse, delivery by, 166 
Nurse's outfit, 119 

position for curettage, 269 

room, 246 
Nursery, bacteria in, 285 

furniture of, 285 

temperature of, 285 

ventilation of, 276, 285 
Nursing-bottles, 333 
care of, 334 

hours for, 313 

Oatmeal-water, 334 
Obstetrical pads, 123 
(Edema of lower limbs, 78 
One cow's milk, 326 
Operative delivery, 177 
Ophthalmia neonatorum, 303 
causes of, 303 
dangers of, 303 
prevention of, 303 
symptoms of, 303 
treatment of, 303 
Opisthotonos, 308 
Os, external, 33 

internal, 27 
Osmosis, 47, 54 

Outer garments in pregnancy, 107 
Outfit for infant, 125 

for mother, 123 

for nurse, 119 
Outings for infant, 285 
Ovary, 33< 43 

Overgrowth of foetus, 112 
Ovulation, 37, 38 
Ovule, 33 
Ovum, 37, 43 

at four weeks, 49 



Ovum, impregnation of, 38 
interior of, 43 
segmentation of, 44 

Pads for the bed, 123 

for the vulva, 124 

obstetrical, 123 

sanitary, 124 
Pain, causes of, 91 

effect on breast milk, 323 

in pregnancy, 91 
Pains, false, 152 

of labor, 141 

true, 153 
Palpitation of the heart, 65, 81 
Paralysis, 81 

from forceps, 300 
Parturition, 139 
Passive fetal movements, 103 
Pasteurization of milk, 338 
Pasteurizer, Freeman's, 337, 338 
Patient's outfit, 123 
Pelvic contraction, 27 
Pelvimeter, 26 
Pelvimetry, importance of, 26 

external, 26 

internal, 27 
Pelvis, 22 

articulations of, 24 

brim of, 23 

deformed, 26 

inclined planes of, 131 

in pregnancy, 69 

inlet of, 23 

joints of, 24 

male and female, 24 
Perforator, 196 
Perineum, 33 

prevention of laceration, 167 
Pernicious vomiting, 72 
Phenomena, emotional, of preg- 
nancy, 100 

mental, of pregnancy, 100 

of labor, 139 



398 



INDEX. 



Phlegmasia alba dolens, 251 
Physician, when summoned to 

labor, 149 
Physiology of pregnancy, 64 

of the puerperium, 224 
Pigmentation of abdomen, 68 

of breasts, 68, 101 
Piles, 78 
Ping-pong, no 
Placenta, 38, 47 
birth of, 165 
delivery of, 172 
formation of, 49 
in twin cases s 60 
praevia, 93 

central, 93 
dangers of, 94 
hemorrhage from, 94 
lateral, 94 
marginal, 94 
symptoms of, 94 
treatment of, 94 
retained, 213 
Placental attachment, 94 
Playing with infant, 285 
Pneumonia, 95 
Poisoning, by lead, 96 
by sewer-gas, 96 
Position, 129 

knee-chest, 209 
lithotomy, 263 
of nurse for curettage, 269 
Sims's, 199 
Trendelenburg, 209 
Walcher, 182 
Positive signs of pregnancy, 99 
Post-partum hemorrhage, 215 
causes of, 215 
treatment of, 206, 217, 218 
Precipitate labor, 175 
Pregnancy, abdominal, 92 

abdominal changes in, 102 

markings in, 102 
accidents, emergencies of, 201 



Pregnancy, albuminuria of, 

83 
appetite in, 67 
ascites in, 80 
bedroom in, in 
blood changes in, 66 
breast changes in, 101 
castor oil in, 75 
chorea in, 82 
clothing in, 105 
constipation in, 74, 115 
corsets in, 105 
cough in, 67, 81 
craving for unusual food, 114 
dancing in, no 
decidua of, 45 

decollete gowns in, 107, 117 
diarrhoea in, 65, 116 
diet in, 112 
diet-sheet during, 114 
digestive organs in, 67 
disorders of, 71 
dropsy in, 80 
duration of, 139 
dyspnoea in, 67, 76 
eclampsia in, 84 
effect on milk, 323 
eruptive fevers in, 95 
excretive organs in, 67 
exercise in, 107 
extra-uterine, 91 
fainting in, 81, 201 
gait in, 69 
garters in, 107 
growth of hair during, 67 
headache in, 81 
hemorrhage in, 89, 95, 201 
hemorrhoids in, 78 
insanity of, 258 
insomnia in, 80 
interstitial, 92 
itching in, 82 
lacing in, 106 
last two months of, 116 



INDEX. 



399 



Piegnancy, leucorrhcea in, 82 
lungs in, 66 
malaria in, 95 
management of, 105 
maximum duration of, 139 
mental and emotional phenom- 
ena of, 100 
minimum duration of, 139 
nausea of, 71 
nervous affections of, 69 

condition in, 116 
neuralgia in, 81 
outer garments in, 107 
palpitation in, 81 
paralysis in, 81 
pelvic changes in, 69 
physiology of, 62 
pneumonia in, 96 
positive signs of, 99 
presumptive signs of, 99 
probable signs of, 99 
pruritus in, 82 
ptyalism in, 82 
quinine in, 96 
salivation in, 82 
scarlet fever in, 95 
secretive organs in, 67 
sewing-machine in, no 
signs and symptoms of, 98 
skir in, 67 

skin markings of, 68 
sleep in, in 
syncope in, 81, 201 
syphilis in, 96 
teeth in, in 
temperature in, 67 
tubal, 92 

tuberculosis in, 97 
underwear in, 106 
urinary analyses in, 116 
urine of, 69 

uterine displacement in, 83 
varicose veins in, 76 
vomiting of, 71, 99 



Pregnancy, walking in, 107 
" whites" in, 82 
woollen-wear in, 106 
Premature infant, 287 

amount of food for, 297 

artificial feeding of, 298 

bathing, 294 

cord dressing, 287 

cotton jacket for, 288 

cry of, 293 

development of, 298 

diapers for, 288 

" feeder" for, 296 

food for, 295 

in basket, 290 

incubator for, 291 

light for, 294 

manipulation of, 294 

noise, 294 

rest for, 294 

skin of, 294 

temperature of, 295 

turban for, 290 

visitors to, 295 

weight of, 287, 295 
labor, 261, 269 

induction of, 199 
Premonitory symptoms of labor, 

139 
Preparations for Csesarean section, 
188 

for curettage, 264 

for forceps, 181 

for labor, 144 

for labor — last moments, 149 

for symphyseotomy, 192 

for version, 179 
Presentation, 129 

arm, 138 

breech, 134 

brow, 134 

face, 133 

foot, 138 

impacted shoulder, 197 



400 



INDEX. 



Presentation, shoulder, 138 

vertex, 130, 131 
Pressure from forceps, 300 
Presumptive signs of pregnancy, 

99 
Prevention of miscarriage, 204 
Probable date of labor, 138 

signs of pregnancy, 99 
Prolapse of cord, 207 

treatment of, 209 
Promontory of sacrum, 23 
Proteids in milk, 320 
Pruritus, 82 
Ptyalism, 80 

treatment of, 80 
Puberty, 40 

management of, 41 

phenomena of, 41 
Pubis, 23 

symphysis, 24 
Puerperal fever, 248 
cause of, 248 
onset, 249 
symptoms of, 249 
treatment of, 249 
varieties of, 248 

insanity, 258 

mania, 258 

melancholia, 259 

septicaemia, 248 

state, 224 
Puerperium, accidents and emer- 
gencies of, 213 

appetite in, 227 

bathing in, 245 

bowels in, 242 

care of bed, 238 

catheterization in, 239 

chill in, 224 

comfort of patient, 245 

constipation in, 227 

diet in, 245 

disorders of, 248 

eclampsia in, 213 



Puerperium, flowers, 246 

insanity of, 258 

management of, 228 
of fundus, 228 

massage of breasts, 253 

patient's toilet, 231 

physiology of, 224 

pulse in, 224 

retention of urine in, 227 

temperature in, 225, 244 

urination in, 239 

uterus in, 225 

vagina in, 226 

visitors, 246 

vulva in, 226 
Pulse after labor, 224 

in puerperium, 224 
Pus in milk, 323 

Quadruplets, formation of, 60 

frequency of, 60 
Quinine in pregnancy, 97 

Rapid delivery, 200 
Record charts for nurses, 122 
Regurgitation, 317 
Relaxation of fundus, 229 
Resistant forces of labor, 129 
Respiration, artificial, 211 
Rest for premature infant, 294 
Restitution, 132 
Retained placenta, 213 
Retention of urine, 227 
Rocking infant, 284 
Room for nurse, 246 
Rotation, external, 132 
Rupture of ectopic sac, 202 
of uterus, 205 

St. Anthony's dance, 82 
St. John's dance, 82 
St. Vitus's dance, 82 
Sacro-coccygeal articulation, 24 
Sacro-iliac synchondrosis, 24 



INDEX. 



401 



Sacrum, 23 

promontory of, 23 
Saline infusion, 220 
Salivation, 80 

treatment of, 80 
Salt water still bathing, no 

surf bathing, in 
Sanitary pads, 124 
" Scalding" of buttocks, 282 
Scalp, crusts of, 283 
Scarlet fever, 96 
Seborrhcea capitis, 283 
Second stage, conduct of, 158 
Secretive organs in pregnancy, 67 
Section, Cesarean, 186 
Segmentation, 44 
Separation of umbilical cord, 286 
Septicaemia, puerperal, 248 
'' Seven months baby," 139 
Sewer-gas poisoning, 97 
Sewing-machine, use in pregnancy, 

no 
Sex, control of, 343 
Shoulder presentation, 138 
Shoulders, delivery of, 168 
Shower bath, no 
Signs and symptoms of pregnancy, 

98 
Simpson forceps, 182 
Sims's position, 199 
Size of abdomen at different 
months, 102, 103 

of nipple, 334 
Skin in pregnancy, 67 

of premature infant, 294 

markings in pregnancy, 68 
Sleep, in 

infant's, 284 
" Sloane Maternity" Measuring- 
Glass, 333 
Soap, Synol, 124 

tincture of green, 124 
" Soft spot," 55 
Sounds of fetal heart, 104 



Spermatozoa, 38 
Spermatozoon, 43 
Spina bifida, 305 
Spray, no 
Square knot, 170 
Stages of labor, 141 
State, lying-in, 224 

puerperal, 224 
Sterilization of catheter, 240 

of forceps, 184 

of milk, 336 
Sterilizer, Arnold's, 337 
Striae gravidarum, 64 

of breasts, 66, 117 
Subinvolution of uterus, 225 
Sugar in milk, 320 

of milk, 320 

solution, 312 
Supporter, abdominal, 235 
Surf bathing, 11 1 
Symphyseotomy, 192 

after care, 193 

bed, 193 

knife, 192 

preparation of patient, 192 
Symptoms of labor, 140 

of miscarriage, 204 
Syncope, 81, 201 
Synchondrosis, sacro-iliac, 24 
" Synol Soap," 124 
Syphilis, 97 

frequency of, 97 

of nipple, 258 
Syringe, bulb and valve, 185 

Davidson, 184 

fountain, 233 

Tampon, uterine, 219 

Teeth, care of in pregnancy, in 

Temperature after labor, 225, 244 

in pregnancy, 67 

in puerperium, 225, 244 

of incubator, 293 

of infant's bath, 276 



402 



INDEX. 



Temperature of nursery, 285 

of premature infant, 287, 295 
Tenesmus, vesical, 79 
Tennis, 109 
Tetanus, 308 

Threatened miscarriage, 204 
Third stage, conduct of, 172 
Tincture of green soap, 124 
Top milk, 329 
Trendelenburg position, 209 
Triplets, formation of, 53 

frequency of, 61 
Trismus, 308 
True labor-pains, 153 
Tubal pregnancy, 92 
Tuberculosis, 95 
Tubercles of Montgomery, 65 
Tubes, Fallopian, 33 
Tucker-McLane forceps, 182 
Turban for premature infant, 290 
" Twelve per cent, milk," 329 
Twins, 61 

causation of, 61 

delivery of, 174 

formation of, 61 

frequency of, 61 

locked, 174 

placental formation, 61 

sex of, 61 

Umbilical arteries, 60 
cord, 47 

dressing, 272 
formation of, 47 
hemorrhage from, 299 
separation of, 286 
hernia, 307 
vegetations, 308 
Umbilicus, 47 

in pregnancy, 64 
Unassisted labor, 151 
Unavoidable hemorrhage, 202 
Underwear in pregnancy, 106 
Ursemic convulsions, 113 



Urethra, 29 

Urination in puerperium, 239 

Urine, analyses in pregnancy, 116 

examinations of, 69 

of pregnancy, 69 

retention of, 227 
Uterine tampon, 219 
Uterus, 29 

after labor, 225 

body of, 32 

cavity of, 32 

cervix, 32 

displacements of, 83 

fundus, 32 

in puerperium, 225 

inversion of, 206 

involution of, 117, 225 

method of packing, 218 

neck of, 32 

of pregnancy, 62 

openings into, 33 

rupture of, 205 

subinvolution of, 225 

Vagina, 29 

after labor, 226 

in puerperium, 226 

secretion of, 29 
Vaginal discharge in infancy, 307 

examination, 156 

preparation for, 156 

douche, 243 
Varicose veins, 76 

symptoms of, 77 
treatment of, 77 
Vegetations, umbilical, 308 
Ventilation of incubator, 292 

of lying-in room, 246 

of nursery, 276, 285 
Vernix caseosa, 51 
Version, 177 

anaesthesia in, 179, 180 

bipolar, 178 

Braxton-Hicks, 178 



INDEX. 



403 



Version, combined, 178 

dangers of, 180 

external, 178 

indications for, 184 

internal, 180 

preparations for, 179 
Vertex presentation, 131 

mechanism of, 131 
Vesical tenesmus, 69 
Visitors to infant, 285 

to patient, 246 

to premature infant, 294 
Vomiting after nursing, 317 

late in pregnancy, 74 

of pregnancy, 71, 99 

pernicious, 72 

severe types of, ^2 
Vulva, 29 



Vulva after labor, 226 
in puerperium, 226 
pads, 124 

Walcher posture, 182 

Walking, 107, 109 

Weight of normal infant, 51 

of premature infant, 287, 295 
Wet-nurse, 324 
Wharton's jelly, 50 
" Whites," 82 

Withdrawal of catheter, 242 
Woollen-wear in pregnancy, 106 
Womb. See Uterus, 29 
Worry, effect on breast milk, 323 

" Z-O" plaster, 307 



THE END. 



Mb 13 I90f 



LIBRARY OF CONGRESS 



022 216 249 A 



